North Carolina 2025-2026 Regular Session

North Carolina Senate Bill S315 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
1	1		GENERAL ASSEMBLY OF NORTH CAROLINA
2	2		SESSION 2025
3		-	S 1
4		-	SENATE BILL 315
	3	+	S D
	4	+	SENATE BILL DRS45172-MR-110
	5	+
5	6
6	7
7	8		Short Title: More Transparency/Efficiency in Utiliz. Rev. (Public)
8	9		Sponsors: Senators Burgin, Galey, and Sawrey (Primary Sponsors).
9		-	Referred to: ~~Health Care~~
10		-	~~March 18, 2025~~
11		-	~~S315 -v-1~~
	10	+	Referred to:
	11	+
	12	+	DRS45172 -MR-110
12	13		A BILL TO BE ENTITLED 1
13	14		AN ACT TO INCREASE TRANSPARENCY AND EFFICIENCY IN UTILIZATION 2
14	15		REVIEWS. 3
15	16		The General Assembly of North Carolina enacts: 4
16	17		SECTION 1.(a) G.S. 58-50-61 reads as rewritten: 5
17	18		"§ 58-50-61. Utilization review. 6
18	19		(a) Definitions. – As used The following definitions apply in this section, in 7
19	20		G.S. 58-50-62, and in Part 4 of this Article, the term:Article: 8
20	21		… 9
21	22		(16a) Urgent health care service. – A health care service with respect to which the 10
22	23		application of the time periods for making an urgent care determination that, 11
23	24		in the opinion of a physician with knowledge of the covered person's medical 12
24	25		condition, meets either of the following criteria: 13
25	26		a. Could seriously jeopardize the life or health of the covered person or 14
26	27		the ability of the covered person to regain maximum function. 15
27	28		b. Would subject the covered person to severe pain that cannot be 16
28	29		adequately managed without the care or treatment that is the subject 17
29	30		of the utilization review. 18
30	31		… 19
31	32		(f) Time Lines for Prospective and Concurrent Utilization Reviews Based Upon Type of 20
32	33		Health Care Service. – As used in this subsection, the term "necessary information" includes the 21
33	34		results of any patient examination, clinical evaluation, or second opinion that may be required. 22
34	35		Prospective and concurrent determinations shall be communicated to The time line for 23
35	36		completion of a prospective or concurrent utilization review is as follows: 24
36	37		(1) Non-urgent health care services. – If an insurer requires a utilization review of 25
37	38		a healthcare service, then the insurer or its URO shall both render a utilization 26
38	39		review determination or noncertification and notify the covered person and the 27
39	40		covered person's provider within three business days after the insurer obtains 28
40	41		all necessary information about the admission, procedure, or health care 29
41	42		service. to make the utilization review determination or noncertification. 30
42	43		(2) Urgent health care services. – An insurer or its URO shall both render a 31
43	44		utilization review determination or noncertification concerning urgent health 32
44	45		care services and notify the covered person and the covered person's provider 33
45	46		of that utilization review determination or noncertification not later than 24 34
46	47		hours after receiving all necessary information needed to complete the review 35
47		-	of the requested health care services. If the covered person's provider or the 36 General Assembly Of North Carolina Session 2025
48		-	Page 2 Senate Bill 315-First Edition
	48	+	of the requested health care services. If the covered person's provider or the 36
	49	+	FILED SENATE
	50	+	Mar 17, 2025
	51	+	S.B. 315
	52	+	PRINCIPAL CLERK General Assembly Of North Carolina Session 2025
	53	+	Page 2 DRS45172-MR-110
49	54		insurer, or the entity conducting the review on behalf of the insurer, do not 1
50	55		both have access to the electronic health records of the covered person, then 2
51	56		this subdivision shall not apply and the utilization review will be subject to 3
52	57		the time line under subdivision (1) of this subsection. 4
53	58		(f1) Utilization Review Determination Notifications. – If an insurer or its URO certifies a 5
54	59		health care service, the insurer shall notify notification shall be sent to the covered person's 6
55	60		provider. For If an insurer or its URO issues a noncertification, the insurer shall notify the covered 7
56	61		person's provider and send then written or electronic confirmation of the noncertification to the 8
57	62		covered person's provider and covered person. In person that is in compliance with subsection 9
58	63		(h) of this section. 10
59	64		(f2) Concurrent Review Liability. – For concurrent reviews, the insurer shall remain liable 11
60	65		for health care healthcare services until the covered person has been notified of the 12
61	66		noncertification. 13
62	67		… 14
63	68		(j1) Requirements Applicable to Appeals Reviews. – All of the following requirements 15
64	69		apply to an appeals review: 16
65	70		(1) Except as otherwise provided, appeals shall be reviewed by a medical doctor 17
66	71		who meets all of the following criteria: 18
67	72		a. Possesses a current and valid non-restricted license to practice 19
68	73		medicine in any United States jurisdiction. 20
69	74		b. Has practiced for a period of at least three consecutive years in the 21
70	75		same or similar specialty as a medical doctor who typically manages 22
71	76		the medical condition or disease for which utilization review is 23
72	77		required or whose training and experience meets all of the following 24
73	78		criteria: 25
74	79		1. Includes treatment of the same condition as the condition of 26
75	80		the covered person. 27
76	81		2. Includes treatment of complications that may result from the 28
77	82		service or procedure that is the subject of the appeal. 29
78	83		3. Is sufficient for the medical doctor to determine if the service 30
79	84		or procedure is medically necessary or clinically appropriate. 31
80	85		c. Had no direct involvement in making any prior adverse determination 32
81	86		or noncertification. 33
82	87		d. Has no financial interest, or other conflict of interest, in the outcome 34
83	88		of the appeal. 35
84	89		(2) Appeals initiated by a licensed mental health professional for a service 36
85	90		provided by a licensed mental health professional may be reviewed by a 37
86	91		licensed mental health professional rather than a medical doctor. The 38
87	92		requirements of subdivision (1) of this subsection shall apply to the reviewing 39
88	93		licensed mental health professional in the same manner that they apply to a 40
89	94		medical doctor. 41
90	95		(3) The medical doctor or licensed mental health professional shall consider all 42
91	96		known clinical aspects of the healthcare service under review, including all 43
92	97		pertinent medical records and any medical literature that have been provided 44
93	98		by the covered person's provider or by a health care facility. 45
94	99		… 46
95	100		(m) Disclosure of Utilization Review Requirements. – All of the following apply to an 47
96	101		insurer's responsibility to disclose any utilization review procedures: 48
97	102		(1) Coverage and member handbook. – In the certificate of coverage and member 49
98	103		handbook provided to covered persons, an insurer shall include a clear and 50
99	104		comprehensive description of its utilization review procedures, including the 51 General Assembly Of North Carolina Session 2025
100		-	~~Senate Bill 315-First Edition~~ Page 3
	105	+	DRS45172-MR-110 Page 3
101	106		procedures for appealing noncertifications and a statement of the rights and 1
102	107		responsibilities of covered persons, including the voluntary nature of the 2
103	108		appeal process, with respect to those procedures. An insurer shall also include 3
104	109		in the certificate of coverage and the member handbook information about the 4
105	110		availability of assistance from the Department's Health Insurance Smart NC, 5
106	111		including the telephone number and address of the Program. program. 6
107	112		(2) Prospective materials. – An insurer shall include a summary of its utilization 7
108	113		review procedures in materials intended for prospective covered persons. 8
109	114		(3) Membership cards. – An insurer shall print on its membership cards a toll-free 9
110	115		telephone number to call for utilization review purposes. 10
111	116		(4) Website. – An insurer shall make any current utilization review requirements 11
112	117		and restrictions readily accessible on its website. 12
113	118		(m1) Changes to Utilization Review. – If an insurer intends either to implement a new 13
114	119		utilization review requirement or restriction or to amend an existing requirement or restriction, 14
115	120		then the new or amended requirement shall not be in effect unless and until the insurer's website 15
116	121		has been updated to reflect the new or amended requirement or restriction. A claim shall not be 16
117	122		denied for failure to obtain a prior authorization if the prior authorization requirement or amended 17
118	123		requirement was not in effect on the date of service of the claim. 18
119	124		… 19
120	125		(n1) Utilization Review Determination Validity. – All of the following apply to the length 20
121	126		of time an approved prior authorization shall remain valid under certain circumstances: 21
122	127		(1) If a covered person enrolls in a new health benefit plan offered by the same 22
123	128		insurer under which the prior authorization was approved, then the previously 23
124	129		approved prior authorization remains valid for the initial 90 days of coverage 24
125	130		under the new heath benefit plan. This section does not require coverage of a 25
126	131		service if it is not a covered service under the new health benefit plan. 26
127	132		(2) If a healthcare service, other than for in-patient care, requires prior 27
128	133		authorization and is for the treatment of a covered person's chronic condition, 28
129	134		then the prior authorization shall remain valid for no less than six months from 29
130	135		the date the healthcare provider receives notification of the prior authorization 30
131	136		approval. 31
132	137		… 32
133	138		(o) Violation. – A In accordance with this Chapter, a violation of this section subjects an 33
134	139		insurer and an agent of the insurer to G.S. 58-2-70. 34
135	140		(p) Federal Rule Alignment. – No later than January 1, 2028, an insurer offering a health 35
136	141		benefit plan or a utilization review agent acting on behalf of an insurer offering a health benefit 36
137	142		plan, shall implement and maintain a prior authorization application programming interface 37
138	143		meeting the requirements under 45 C.F.R. § 156.223(b) as it existed on January 1, 2025, which 38
139	144		is to be in effect on January 1, 2028. 39
140	145		(q) Reserved for future codification purposes. 40
141	146		(r) Reserved for future codification purposes. 41
142	147		(s) Artificial Intelligence. – An insurer shall not use an artificial intelligence-based 42
143	148		algorithm as the sole basis for a utilization review determination to, in whole or in part, deny, 43
144	149		delay, or modify any healthcare services for an insured. Only individuals meeting the licensing 44
145	150		and qualification requirements for participating in the utilization review process under this 45
146	151		section shall make a determination regarding the medical necessity or appropriateness of any 46
147	152		healthcare service. Insurers shall verify that all contracts with a third party, including with a 47
148	153		pharmacy benefits manager, for conducting any utilization review are not in violation of this 48
149	154		subsection." 49
150	155		SECTION 1.(b) In accordance with G.S. 135-48.24(b) and G.S. 135-48.30(a)(7) 50
151	156		which require the State Treasurer to implement procedures that are substantially similar to the 51 General Assembly Of North Carolina Session 2025
152		-	Page 4 ~~Senate Bill 315-First Edition~~
	157	+	Page 4 DRS45172-MR-110
153	158		provisions of G.S. 58-50-61 for the North Carolina State Health Plan for Teachers and State 1
154	159		Employees (State Health Plan), the State Treasurer and the Executive Administrator of the State 2
155	160		Health Plan shall review all practices of the State Health Plan and all contracts with, and practices 3
156	161		of, any third party conducting any utilization review on behalf of the State Health Plan to ensure 4
157	162		compliance with subsection (a) of this section no later than the start of the next plan year. 5
158	163		SECTION 2. Section 1(a) of this act becomes effective October 1, 2026, and applies 6
159	164		to insurance contracts, including contracts with utilization review organizations, issued, renewed, 7
160	165		or amended on or after that date. The remainder of this act is effective when it becomes law. 8