FIRSTREGULARSESSION
HOUSEBILLNO.618
103RDGENERALASSEMBLY
INTRODUCEDBYREPRESENTATIVESTINNETT.
0990H.01I DANARADEMANMILLER,ChiefClerk
ANACT
Toamendchapter376,RSMo,byaddingtheretofivenewsectionsrelatingtoprior
authorizationofhealthcareservices.
BeitenactedbytheGeneralAssemblyofthestateofMissouri,asfollows:
SectionA.Chapter376,RSMo,isamendedbyaddingtheretofivenewsections,tobe
2knownassections376.2100,376.2102,376.2104,376.2106,and376.2108,toreadas
3follows:
376.2100.1.Exceptasotherwiseprovidedinsubsection1ofsection376.2108,as
2usedinsections376.2100to376.2108,termsshallhavethesamemeaningsasare
3ascribedtothemundersection376.1350.
4 2.Asusedinsections376.2100to376.2108,theterm"evaluationperiod"shall
5meanthefirstsixmonthsofthecalendaryearorthelastsixmonthsofthecalendar
6year.
376.2102.1.Ahealthcarrierorutilizationreviewentityshallnotrequirea
2healthcareprovidertoobtainpriorauthorizationforahealthcareserviceunlessthe
3healthcarrierorutilizationreviewentitymakesadeterminationthatinthemostrecent
4evaluationperiodthehealthcarrierorutilizationreviewentityhasapprovedorwould
5haveapprovedlessthanninetypercentofthepriorauthorizationrequestssubmittedby
6thatproviderforthathealthcareservice.
7 2.Ahealthcarrierorutilizationreviewentityshallnotrequireahealthcare
8providertoobtainpriorauthorizationforanyhealthcareservicesunlessthehealth
9carrierorutilizationreviewentitymakesadeterminationthatinthemostrecent
10evaluationperiodthehealthcarrierorutilizationreviewentityhasapprovedorwould
EXPLANATION—Matterenclosedinbold-facedbrackets[thus] intheabovebillisnotenactedandis
intendedtobeomittedfromthelaw.Matterinbold-facetypeintheabovebillisproposedlanguage. 11haveapprovedlessthanninetypercentofallpriorauthorizationrequestssubmittedby
12thatproviderforhealthcareservices.
13 3.Inmakingadeterminationunderthissection,thehealthcarrierorutilization
14reviewentityshallnotcountanypriorauthorizationrequestsdeniedbyahealthcarrier
15orutilizationreviewentityandbeingappealedbythehealthcareproviderbutshall
16countasapprovedanypriorauthorizationrequestthatwasdeniedbyahealthcarrier
17orutilizationreviewentitybutthatwassubsequentlyauthorized.
376.2104.1.Thehealthcarrierorutilizationreviewentityshallnotifythehealth
2careprovidernolaterthantwenty-fivedaysaftertheconclusionoftherelevant
3evaluationperiodofanydeterminationmadeundersection376.2102.Thenotification
4shallincludethestatistics,data,andanysupportingdocumentationformakingthe
5determinationfortherelevantevaluationperiod.
6 2.Thehealthcarrierorutilizationreviewentityshallestablishaprocessfor
7healthcareproviderstoappealanydeterminationsmadeundersection376.2102.
8 3.Thehealthcarrierorutilizationreviewentityshallmaintainanonlineportal
9toallowhealthcareproviderstoaccessallpriorauthorizationdecisions,including
10determinationsmadeundersection376.2102.Forhealthcareproviderssubjecttoprior
11authorizations,theportalshallincludethestatusofeachpriorauthorizationrequest,all
12notificationstothehealthcareprovider,thedatesthehealthcareproviderreceivedsuch
13notifications,andanyotherinformationrelevanttothedetermination.
376.2106.Nohealthcarrierorutilizationreviewentityshalldenyorreduce
2paymenttoahealthcareproviderforahealthcareserviceforwhichtheproviderhasa
3priorauthorizationunlesstheprovider:
4 (1)Knowinglyandmateriallymisrepresentedthehealthcareserviceinarequest
5forpaymentsubmittedtothehealthcarrierorutilizationreviewentitywiththespecific
6intenttodeceiveandobtainanunlawfulpaymentfromthecarrierorentity;or
7 (2)Failedtosubstantiallyperformthehealthcareservice.
376.2108.1.Theprovisionsofsections376.2100to376.2108shallnotapplyto
2MOHealthNet,exceptthataMedicaidmanagedcareorganizationasdefinedinsection
3208.431shallbeconsideredahealthcarrierforpurposesofsections376.2100to
4376.2108.
5 2.Theprovisionsofsections376.2100to376.2108shallnotapplytohealthcare
6providerswhohavenotparticipatedinahealthbenefitplanofferedbythehealth
7carrierforatleastonefullevaluationperiod.
8 3.Nothinginsections376.2100to376.2108shallbeconstruedto:
9 (1)Authorizeahealthcareprovidertoprovideahealthcareserviceoutsidethe
10scopeofhisorherapplicablelicense;or
HB618 2 11 (2)Requireahealthcarrierorutilizationreviewentitytopayforahealthcare
12servicedescribedinsubdivision(1)ofthissubsection.
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