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H.31 1
Introduced by Representative Black of Essex 2
Referred to Committee on 3
Date: 4
Subject: Health; health insurance; health care providers; claim edits; place of 5
service; prior authorization; primary care providers 6
Statement of purpose of bill as introduced: This bill proposes to specify that 7
otherwise applicable health insurance claim edit standards do not apply when a 8
health care service is delivered outside Vermont, unless otherwise agreed to by 9
the health insurer and the out-of-state provider. It would also modify the 10
definition of a primary care provider for purposes of determining which health 11
care providers’ orders are exempt from prior authorization requirements. 12
An act relating to claim edit standards and prior authorization requirements 13
It is hereby enacted by the General Assembly of the State of Vermont: 14
Sec. 1. 18 V.S.A. § 9418a is amended to read: 15
§ 9418a. PROCESSING CLAIMS, DOWNCODING, AND ADHERENCE 16
TO CODING RULES 17
* * * 18
(c) Adherence to the edit standards in subsection (b) of this section is not 19
required: 20 BILL AS INTRODUCED H.31
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(1) when necessary to comply with State or federal laws, rules, 1
regulations, or coverage mandates; or 2
(2) for edits that the payer determines are more favorable to providers 3
than the edit standards in subsection (b) of this section or to address new codes 4
not yet incorporated by a payer’s edit management software, provided the edit 5
standards are: 6
(A) developed with input from the relevant Vermont provider 7
community and national provider organizations; 8
(B) clearly supported by nationally recognized standards, guidelines, 9
or conventions approved by the Commissioner of Financial Regulation; and 10
(C) available to providers on the plan’s websites and in its 11
newsletters or equivalent electronic communications; or 12
(3) when adjudicating claims for health care services that were delivered 13
outside the State of Vermont, unless the payer and the out-of-state provider 14
agree that one or more of the edit standards set forth in subsection (b) of this 15
section will apply. 16
* * * 17
Sec. 2. 18 V.S.A. § 9418b is amended to read: 18
§ 9418b. PRIOR AUTHORIZATION 19
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(c)(1)(A) Except as provided in subdivision (B) of this subdivision (1), a 1
health plan shall not impose any prior authorization requirement for any 2
admission, item, service, treatment, or procedure ordered by a primary care 3
provider. 4
(B) The prohibition set forth in subdivision (A) of this subdivision 5
(1) shall not be construed to prohibit prior authorization requirements for 6
prescription drugs or for an admission, item, service, treatment, or procedure 7
that is provided out-of-network. 8
(2) As used in this subsection, “primary care provider” has the same 9
meaning as is used by the Vermont Blueprint for Health means a health care 10
provider who is contracted and enrolled with the health plan as a primary care 11
provider. 12
* * * 13
Sec. 3. EFFECTIVE DATES 14
(a) Sec. 1 (18 V.S.A. § 9418a) shall take effect on January 1, 2026. 15
(b) Sec. 2 (18 V.S.A. § 9418b) shall take effect on passage and shall be 16
implemented by all health plans as soon as reasonably practicable after that 17
date, but in no event later than January 1, 2026. 18
(c) This section shall take effect on passage. 19