HB618--PRIORAUTHORIZATIONOFHEALTHCARESERVICES
SPONSOR: Stinnett
Thisbillprovidesthatahealthcarrierorutilizationreview
entitycannotrequirehealthcareproviderstoobtainprior
authorizationforhealthcareservices,exceptundercertain
circumstances.
Priorauthorizationisnotrequiredunlessadeterminationismade
thatlessthan90%ofpriorauthorizationrequestssubmittedbythe
healthcareproviderinthepreviousevaluationperiod,asdefined
inthebill,wereorwouldhavebeenapproved.
Thebillestablishesseparatethresholdsforrequiringprior
authorizationforindividualhealthcareservicesorrequiring
priorauthorizationforallhealthcareservices.
Thebillspecifiesrequirementsfornotifyingtheproviderof
determinations inthebill,requirescarriersandutilization
reviewentitiestomaintainanonlineportalgivingproviders
accesstocertaininformation,andprovidesthatprior
authorizations mayberequiredbeginning25businessdaysafter
noticetotheprovideruntiltheendoftheevaluationperiod.
Failuretonotifyprovidersofadeterminationasrequiredinthe
billwillconstitutepriorauthorizationoftheapplicablehealth
careservices.
Lastly,nohealthcarrierorutilizationreviewentitycandenyor
reducepaymentstoahealthcareproviderwhohadaprior
authorization, unlesstheprovidermadeaknowingandmaterial
misrepresentation withtheintenttodeceivethecarrieror
utilizationreviewentity,orunlessthehealthcareservicewas
notsubstantiallyperformed.
ThisbillwillnotapplytoMedicaid,exceptwithregardtoa
Medicaidmanagedcareorganizationasdefinedbylaw.Thebill
alsodoesnotapplytoproviderswhohavenotparticipatedina
healthbenefitplanofferedbythecarrierforatleastonefull
evaluationperiod.
Thisbillshouldnotbeconstruedtoauthorizeproviderstoprovide
servicesoutsidethescopeoftheirlicenses,nortorequirehealth
carriersorutilizationreviewentitiestopayforcareprovided
outsidethescopeofaprovider'slicense.
ThisbillisthesameasHB1976(2024).