FIRST REGULAR SESSION
SENATE BILL NO. 230
103RD GENERAL ASSEMBLY
INTRODUCED BY SENATOR BROWN (26).
0591S.01I KRISTINA MARTIN, Secretary
AN ACT
To amend chapter 376, RSMo, by adding thereto five new sections relating to prior authorization
of health care services.
Be it enacted by the General Assembly of the State of Missouri, as follows:
Section A. Chapter 376, RSMo, is amended by adding thereto 1
five new sections, to be known as sections 376.2100, 376.2102, 2
376.2104, 376.2106, and 376.2108, to read as follows:3
376.2100. 1. Except as otherwise provided in 1
subsection 1 of section 376.2108, as used in sections 2
376.2100 to 376.2108, terms shall have the same meanings as 3
are ascribed to them under section 376.1350. 4
2. As used in sections 376.2100 to 376.2108, the term 5
"evaluation period" shall mean the first six months of the 6
calendar year or the last six months of the calendar year. 7
376.2102. 1. A health carrier or utilization review 1
entity shall not require a health care provider to obtain 2
prior authorization for a health care service unless the 3
health carrier or utilization review entity ma kes a 4
determination that in the most recent evaluation period the 5
health carrier or utilization review entity has approved or 6
would have approved less than ninety percent of the prior 7
authorization requests submitted by that provider for that 8
health care service. 9
2. A health carrier or utilization review entity shall 10
not require a health care provider to obtain prior 11 SB 230 2
authorization for any health care services unless the health 12
carrier or utilization review entity makes a determination 13
that in the most recent evaluation period the health carrier 14
or utilization review entity has approved or would have 15
approved less than ninety percent of all prior authorization 16
requests submitted by that provider for health care services. 17
3. In making a determination under this section, the 18
health carrier or utilization review entity shall not count 19
any prior authorization requests denied by a health carrier 20
or utilization review entity and being appealed by the 21
health care provider but shall count a s approved any prior 22
authorization request that was denied by a health carrier or 23
utilization review entity but that was subsequently 24
authorized. 25
376.2104. 1. The health carrier or utilization review 1
entity shall notify the health care provider no later than 2
twenty-five days after the conclusion of the relevant 3
evaluation period of any determination made under section 4
376.2102. The notification shall include the statistics, 5
data, and any supporting documentation for making the 6
determination for the relevant evaluation period. 7
2. The health carrier or utilization review entity 8
shall establish a process for health care providers to 9
appeal any determinations made under section 376.2102. 10
3. The health carrier or utili zation review entity 11
shall maintain an online portal to allow health care 12
providers to access all prior authorization decisions, 13
including determinations made under section 376.2102. For 14
health care providers subject to prior authorizations, the 15
portal shall include the status of each prior authorization 16
request, all notifications to the health care provider, the 17 SB 230 3
dates the health care provider received such notifications, 18
and any other information relevant to the determination. 19
376.2106. No health carrier or utilization review 1
entity shall deny or reduce payment to a health care 2
provider for a health care service for which the provider 3
has a prior authorization unless the provider: 4
(1) Knowingly and materially misreprese nted the health 5
care service in a request for payment submitted to the 6
health carrier or utilization review entity with the 7
specific intent to deceive and obtain an unlawful payment 8
from the carrier or entity; or 9
(2) Failed to substantially perfo rm the health care 10
service. 11
376.2108. 1. The provisions of sections 376.2100 to 1
376.2108 shall not apply to MO HealthNet, except that a 2
Medicaid managed care organization as defined in section 3
208.431 shall be considered a health c arrier for purposes of 4
sections 376.2100 to 376.2108. 5
2. The provisions of sections 376.2100 to 376.2108 6
shall not apply to health care providers who have not 7
participated in a health benefit plan offered by the health 8
carrier for at least one fu ll evaluation period. 9
3. Nothing in sections 376.2100 to 376.2108 shall be 10
construed to: 11
(1) Authorize a health care provider to provide a 12
health care service outside the scope of his or her 13
applicable license; or 14
(2) Require a health carrier or utilization review 15
entity to pay for a health care service described in 16
subdivision (1) of this subsection. 17