| 17 | | - | 4 2.Asusedinsections376.2100to376.2108,thefollowingtermsmean: |
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| 18 | | - | 5 (1)"Evaluationperiod",anyconsecutivetwelvemonths; |
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| 19 | | - | 6 (2)"Value-basedcareagreement",acontractualagreementbetweenahealth |
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| 20 | | - | 7careprovider,eitherdirectlyorindirectlythroughahealthcareprovidergroupor |
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| 21 | | - | 8organization,andahealthcarrierthat: |
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| 22 | | - | 9 (a)Incentivizesorrewardsprovidersbasedononeormoreofthefollowing: |
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| 23 | | - | 10 a.Qualityofcare; |
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| 24 | | - | 11 b.Safety; |
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| 25 | | - | 12 c.Patientoutcomes; |
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| 26 | | - | 13 d.Efficiency; |
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| 27 | | - | 14 e.Costreduction;or |
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| 28 | | - | 15 f.Otherfactors;and |
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| 16 | + | 4 2.Asusedinsections376.2100to376.2108,theterm"evaluationperiod"shall |
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| 17 | + | 5meanthefirstsixmonthsofthecalendaryearorthelastsixmonthsofthecalendar |
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| 18 | + | 6year. |
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| 19 | + | 376.2102.1.Ahealthcarrierorutilizationreviewentityshallnotrequirea |
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| 20 | + | 2healthcareprovidertoobtainpriorauthorizationforahealthcareserviceunlessthe |
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| 21 | + | 3healthcarrierorutilizationreviewentitymakesadeterminationthatinthemostrecent |
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| 22 | + | 4evaluationperiodthehealthcarrierorutilizationreviewentityhasapprovedorwould |
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| 23 | + | 5haveapprovedlessthanninetypercentofthepriorauthorizationrequestssubmittedby |
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| 24 | + | 6thatproviderforthathealthcareservice. |
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| 25 | + | 7 2.Ahealthcarrierorutilizationreviewentityshallnotrequireahealthcare |
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| 26 | + | 8providertoobtainpriorauthorizationforanyhealthcareservicesunlessthehealth |
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| 27 | + | 9carrierorutilizationreviewentitymakesadeterminationthatinthemostrecent |
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| 28 | + | 10evaluationperiodthehealthcarrierorutilizationreviewentityhasapprovedorwould |
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| 30 | | - | intendedtobeomittedfromthelaw.Matterinbold-facetypeintheabovebillisproposedlanguage. 16 (b)May,butisnotrequiredto,includesharedfinancialriskandrewardsbased |
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| 31 | | - | 17onperformancemetrics. |
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| 32 | | - | 376.2102.1.Exceptasotherwiseprovidedinthissection,beginningJanuary1, |
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| 33 | | - | 22026,ahealthcarrierorutilizationreviewentityshallnotrequireahealthcareprovider |
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| 34 | | - | 3toobtainpriorauthorizationforahealthcareserviceunlessthehealthcarrieror |
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| 35 | | - | 4utilizationreviewentitymakesadeterminationthatinthemostrecentevaluationperiod |
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| 36 | | - | 5thehealthcarrierorutilizationreviewentityhasapprovedorwouldhaveapprovedless |
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| 37 | | - | 6thanninetypercentofthepriorauthorizationrequestssubmittedbythatproviderfor |
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| 38 | | - | 7thathealthcareservice. |
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| 39 | | - | 8 2.BeginningJanuary1,2026,ahealthcarrierorutilizationreviewentityshall |
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| 40 | | - | 9notrequireahealthcareprovidertoobtainpriorauthorizationforanyhealthcare |
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| 41 | | - | 10servicesunlessthehealthcarrierorutilizationreviewentitymakesadeterminationthat |
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| 42 | | - | 11inthemostrecentevaluationperiodthehealthcarrierorutilizationreviewentityhas |
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| 43 | | - | 12approvedorwouldhaveapprovedlessthanninetypercentofallpriorauthorization |
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| 44 | | - | 13requestssubmittedbythatproviderforhealthcareservices. |
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| 45 | | - | 14 3.(1)BeginningJanuary1,2026,ahealthcarrierorutilizationreviewentity |
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| 46 | | - | 15mayelecttohaveahospital,asthattermisdefinedinsection197.020,determinewhich |
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| 47 | | - | 16ofthefollowingconditionsthatsuchhospitalwillcomplywithtoobtainanexemption |
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| 48 | | - | 17frompriorauthorizationrequirementsundersubsections1and2ofthissection: |
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| 49 | | - | 18 (a)Thehospitalenteringinto,eitherdirectlyorindirectlythroughahealthcare |
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| 50 | | - | 19providergroupororganizationavalue-basedcareagreementwiththehealthcarrier; |
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| 51 | | - | 20 (b)Thehospital'sscoreofthreeorhigherontheCenterforMedicareand |
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| 52 | | - | 21MedicaidServicesFive-StarQualityRatingSystem,42CFR§412.190,oritssuccessor |
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| 53 | | - | 22ratingsystem;or |
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| 54 | | - | 23 (c)Atleastninety-onepercentofthehospital'spriorauthorizationrequests |
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| 55 | | - | 24submittedforpurposesofeligibilityforsubsections1or2ofthissectionwereapproved |
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| 56 | | - | 25orwouldhavebeenapprovedbythehealthcarrierorutilizationreviewentity. |
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| 57 | | - | 26 (2)CriticalaccesshospitalsandhospitalsthatdonotparticipateintheCenter |
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| 58 | | - | 27forMedicareandMedicaidServicesFive-StarQualityRatingSystem,oritssuccessor |
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| 59 | | - | 28ratingsystem,shallbeexemptfromtheprovisionsofthissubsection. |
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| 60 | | - | 29 4.Theexemptionfrompriorauthorizationrequirementsdescribedin |
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| 61 | | - | 30subsections1,2,and3ofthissectionshallnotinclude: |
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| 62 | | - | 31 (1)Pharmacyservices,nottoexceedtheamountofonehundredthousand |
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| 63 | | - | 32dollars; |
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| 64 | | - | 33 (2)Imagingservices,nottoexceedtheamountofonehundredthousanddollars; |
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| 65 | | - | 34 (3)Cosmeticproceduresthatarenotmedicallynecessary;or |
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| 66 | | - | 35 (4)Investigativeorexperimentaltreatments. |
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| 67 | | - | HB618 2 36 5.Theamountofthelimitationsdescribedinsubdivisions(1)and(2)of |
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| 68 | | - | 37subsection4ofthissectionshallbeincreasedeveryyear,roundedtothenearest |
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| 69 | | - | 38thousanddollars,beginningJanuary1,2027,basedontheConsumerPriceIndexforAll |
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| 70 | | - | 39UrbanConsumersfortheUnitedStates(CPI-U),oritssuccessorindex,assuchindexis |
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| 71 | | - | 40definedandofficiallyreportedbytheUnitedStatesDepartmentofLabor,orits |
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| 72 | | - | 41successoragency. |
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| 73 | | - | 42 6.Inmakingadeterminationunderthissection,thehealthcarrierorutilization |
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| 74 | | - | 43reviewentityshallnotcount: |
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| 75 | | - | 44 (1)Anypriorauthorizationrequestsdeniedbyahealthcarrierorutilization |
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| 76 | | - | 45reviewentityandbeingappealedbythehealthcareprovider;or |
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| 77 | | - | 46 (2)Anyrequestmadebyahealthcareproviderforaservicethatisnotincluded |
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| 78 | | - | 47inthehealthcarrier'sbenefitplan |
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| 79 | | - | 48 |
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| 80 | | - | 49butshallcountasapprovedanypriorauthorizationrequestthatwasdeniedbyahealth |
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| 81 | | - | 50carrierorutilizationreviewentitybutthatwassubsequentlyauthorized. |
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| 82 | | - | 51 7.Inmakingadeterminationunderthissection,thehealthcarrierorutilization |
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| 83 | | - | 52reviewentityshalluseeithertheprovider'snationalprovideridentifierorataxpayer |
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| 84 | | - | 53identificationnumber.Suchdesignationshallremainunlessrequestedtobechangedby |
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| 85 | | - | 54theprovider. |
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| 86 | | - | 55 8.Theexemptionfrompriorauthorizationrequirementsdescribedin |
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| 87 | | - | 56subsections1,2,and3ofthissectionmaybesubjecttointernalauditingofthemost |
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| 88 | | - | 57recentconsecutivesixmonths,uptoamaximumoftwotimesperyear,bythehealth |
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| 89 | | - | 58carrierorutilizationreviewentityandmayberescindedif: |
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| 90 | | - | 59 (1)Suchcarrierorutilizationreviewentitydeterminesthatthecarrieror |
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| 91 | | - | 60utilizationreviewentitywouldhaveapprovedlessthanninetypercentofprior |
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| 92 | | - | 61authorizationrequestsforahealthcareservicethattheproviderwasexemptfromthe |
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| 93 | | - | 62priorauthorizationrequirementundersubsection1ofthissection; |
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| 94 | | - | 63 (2)Suchcarrierorutilizationreviewentitydeterminesthatthecarrieror |
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| 95 | | - | 64utilizationreviewentitywouldhaveapprovedlessthanninetypercentofallprior |
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| 96 | | - | 65authorizationrequestsiftheproviderwasexemptfromthepriorauthorization |
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| 97 | | - | 66requirementundersubsection2ofthissection;or |
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| 98 | | - | 67 (3)Therehasbeenanincreaseintheprovisionofexemptproceduresbyahealth |
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| 99 | | - | 68careproviderofmorethanfiftypercentormorethantwentyprocedures,whichever |
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| 100 | | - | 69amountisgreater. |
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| 101 | | - | 70 9.Theexemptiondescribedinsubsections1,2,and3ofthissectionshallbenull |
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| 102 | | - | 71andvoiduponadeterminationthatthehealthcareproviderhasbeenfoundbyacourt |
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| 103 | | - | HB618 3 72oflawtohavecivillyorcriminallyengagedinanyfraudorabuseaftertheexemptionis |
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| 104 | | - | 73grantedbyahealthcarrierorutilizationreviewentity. |
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| 105 | | - | 74 10.Ahealthcarrierorutilizationreviewentitymayrequirehealthcare |
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| 106 | | - | 75providersinthehealthcarrier'sorutilizationreviewentity'snetworktouseanonline |
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| 107 | | - | 76portaltosubmitrequestsforpriorauthorization. |
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| 108 | | - | 77 11.Noadversedeterminationshallbefinalizedundersubsections1,2,3,or8 |
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| 109 | | - | 78unlessreviewedbyaclinicalpeer. |
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| 110 | | - | 79 12.Anypatientwhohasreceivedpriorauthorizationforthecoverageofa |
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| 111 | | - | 80ninety-daysupplyofmedicationwhosehealthcoverageplanchangesfollowingsuch |
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| 112 | | - | 81authorizationshallbepermittedaninety-daygraceperiodfromthedateofsuchchange |
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| 113 | | - | 82inordertodeterminewhethersuchpatient'snewplancoversthepreviouslyauthorized |
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| 114 | | - | 83medicationorwhetherpriorauthorizationisrequired. |
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| 30 | + | intendedtobeomittedfromthelaw.Matterinbold-facetypeintheabovebillisproposedlanguage. 11haveapprovedlessthanninetypercentofallpriorauthorizationrequestssubmittedby |
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| 31 | + | 12thatproviderforhealthcareservices. |
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| 32 | + | 13 3.Inmakingadeterminationunderthissection,thehealthcarrierorutilization |
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| 33 | + | 14reviewentityshallnotcountanypriorauthorizationrequestsdeniedbyahealthcarrier |
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| 34 | + | 15orutilizationreviewentityandbeingappealedbythehealthcareproviderbutshall |
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| 35 | + | 16countasapprovedanypriorauthorizationrequestthatwasdeniedbyahealthcarrier |
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| 36 | + | 17orutilizationreviewentitybutthatwassubsequentlyauthorized. |
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| 116 | | - | 2careprovidernolaterthantwenty-fivedaysafteranydeterminationmadeunder |
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| 117 | | - | 3section376.2102.Thenotificationshallincludethestatistics,data,andanysupporting |
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| 118 | | - | 4documentationformakingthedeterminationfortherelevantevaluationperiod. |
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| 119 | | - | 5 2.Thehealthcarrierorutilizationreviewentityshallestablishaprocessfor |
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| 120 | | - | 6healthcareproviderstoappealanydeterminationsmadeundersection376.2102. |
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| 121 | | - | 7 3.Thehealthcarrierorutilizationreviewentityshallmaintainanonlineportal |
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| 122 | | - | 8toallowhealthcareproviderstoaccessallpriorauthorizationdecisions,including |
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| 123 | | - | 9determinationsmadeundersection376.2102.Forhealthcareproviderssubjecttoprior |
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| 124 | | - | 10authorizations,theportalshallincludethestatusofeachpriorauthorizationrequest,all |
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| 125 | | - | 11notificationstothehealthcareprovider,thedatesthehealthcareproviderreceivedsuch |
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| 126 | | - | 12notifications,andanyotherinformationrelevanttothedetermination. |
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| 38 | + | 2careprovidernolaterthantwenty-fivedaysaftertheconclusionoftherelevant |
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| 39 | + | 3evaluationperiodofanydeterminationmadeundersection376.2102.Thenotification |
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| 40 | + | 4shallincludethestatistics,data,andanysupportingdocumentationformakingthe |
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| 41 | + | 5determinationfortherelevantevaluationperiod. |
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| 42 | + | 6 2.Thehealthcarrierorutilizationreviewentityshallestablishaprocessfor |
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| 43 | + | 7healthcareproviderstoappealanydeterminationsmadeundersection376.2102. |
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| 44 | + | 8 3.Thehealthcarrierorutilizationreviewentityshallmaintainanonlineportal |
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| 45 | + | 9toallowhealthcareproviderstoaccessallpriorauthorizationdecisions,including |
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| 46 | + | 10determinationsmadeundersection376.2102.Forhealthcareproviderssubjecttoprior |
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| 47 | + | 11authorizations,theportalshallincludethestatusofeachpriorauthorizationrequest,all |
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| 48 | + | 12notificationstothehealthcareprovider,thedatesthehealthcareproviderreceivedsuch |
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| 49 | + | 13notifications,andanyotherinformationrelevanttothedetermination. |
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