| Old | New | Differences | |
|---|---|---|---|
| 1 | - | No. 3 Page 1 of 3 | |
| 2 | - | 2025 | |
| 3 | - | ||
| 4 | - | VT LEG #381459 v.1 | |
| 5 | - | No. 3. An act relating to claim edit standards and prior authorization | |
| 6 | - | requirements. | |
| 7 | - | (H.31) | |
| 1 | + | BILLASPASSEDBYTHEHOUSEANDSENATE H.31 | |
| 2 | + | 2025 Page1of3 | |
| 3 | + | H.31 | |
| 4 | + | IntroducedbyRepresentativeBlackofEssex | |
| 5 | + | ReferredtoCommitteeon | |
| 6 | + | Date: | |
| 7 | + | Subject:Health;healthinsurance;healthcareproviders;claimedits;placeof | |
| 8 | + | service;priorauthorization;primarycareproviders | |
| 9 | + | Statementofpurposeofbillasintroduced:Thisbillproposestospecifythat | |
| 10 | + | otherwiseapplicablehealthinsuranceclaimeditstandardsdonotapplywhena | |
| 11 | + | healthcareserviceisdeliveredoutsideVermont,unlessotherwiseagreedtoby | |
| 12 | + | thehealthinsurerandtheout-of-stateprovider.Itwouldalsomodifythe | |
| 13 | + | definitionofaprimarycareproviderforpurposesofdeterminingwhichhealth | |
| 14 | + | careproviders’ordersareexemptfrompriorauthorizationrequirements. | |
| 15 | + | Anactrelatingtoclaimeditstandardsandpriorauthorizationrequirements | |
| 8 | 16 | ItisherebyenactedbytheGeneralAssemblyoftheStateofVermont: | |
| 9 | - | Sec. | |
| 17 | + | Sec.1.18V.S.A.§ 9418aisamendedtoread: | |
| 10 | 18 | §9418a.PROCESSINGCLAIMS,DOWNCODING, ANDADHERENCE | |
| 11 | 19 | TOCODINGRULES | |
| 12 | 20 | *** | |
| 21 | + | 1 | |
| 22 | + | 2 | |
| 23 | + | 3 | |
| 24 | + | 4 | |
| 25 | + | 5 | |
| 26 | + | 6 | |
| 27 | + | 7 | |
| 28 | + | 8 | |
| 29 | + | 9 | |
| 30 | + | 10 | |
| 31 | + | 11 | |
| 32 | + | 12 | |
| 33 | + | 13 | |
| 34 | + | 14 | |
| 35 | + | 15 | |
| 36 | + | 16 | |
| 37 | + | 17 | |
| 38 | + | 18 BILLASPASSEDBYTHEHOUSEANDSENATE H.31 | |
| 39 | + | 2025 Page2of3 | |
| 13 | 40 | (c)Adherencetotheeditstandardsinsubsection(b)ofthissectionisnot | |
| 14 | 41 | required: | |
| 15 | 42 | (1)whennecessarytocomplywithStateorfederallaws,rules, | |
| 16 | 43 | regulations,orcoveragemandates;or | |
| 17 | 44 | (2)foreditsthatthepayerdeterminesaremorefavorabletoproviders | |
| 18 | 45 | thantheeditstandardsinsubsection(b)ofthissectionortoaddressnewcodes | |
| 19 | 46 | notyetincorporatedbyapayer’seditmanagementsoftware,providedtheedit | |
| 20 | 47 | standardsare: | |
| 21 | 48 | (A)developedwithinputfromtherelevantVermontprovider | |
| 22 | 49 | communityandnationalproviderorganizations; | |
| 23 | 50 | (B)clearlysupportedbynationallyrecognizedstandards,guidelines, | |
| 24 | 51 | orconventionsapprovedbytheCommissionerofFinancialRegulation;and | |
| 25 | 52 | (C)availabletoprovidersontheplan’swebsitesandinits | |
| 26 | - | newsletters or equivalent electronic communications; or No. 3 Page 2 of 3 | |
| 27 | - | 2025 | |
| 28 | - | ||
| 29 | - | VT LEG #381459 v.1 | |
| 53 | + | newslettersorequivalentelectroniccommunications;or | |
| 30 | 54 | (3)whenadjudicatingclaimsforhealthcareservicesthatweredelivered | |
| 31 | 55 | outsidetheStateofVermont,unlessthepayerandtheout-of-stateprovider | |
| 32 | 56 | agreethatoneormoreoftheeditstandardssetforthinsubsection(b)ofthis | |
| 33 | 57 | sectionwillapply. | |
| 34 | 58 | *** | |
| 35 | - | Sec. | |
| 59 | + | Sec.2.18V.S.A.§ 9418bisamendedtoread: | |
| 36 | 60 | §9418b.PRIORAUTHORIZATION | |
| 61 | + | 1 | |
| 62 | + | 2 | |
| 63 | + | 3 | |
| 64 | + | 4 | |
| 65 | + | 5 | |
| 66 | + | 6 | |
| 67 | + | 7 | |
| 68 | + | 8 | |
| 69 | + | 9 | |
| 70 | + | 10 | |
| 71 | + | 11 | |
| 72 | + | 12 | |
| 73 | + | 13 | |
| 74 | + | 14 | |
| 75 | + | 15 | |
| 76 | + | 16 | |
| 77 | + | 17 | |
| 78 | + | 18 | |
| 79 | + | 19 | |
| 80 | + | 20 | |
| 81 | + | 21 BILLASPASSEDBYTHEHOUSEANDSENATE H.31 | |
| 82 | + | 2025 Page3of3 | |
| 37 | 83 | *** | |
| 38 | 84 | (c)(1)(A)Exceptasprovidedinsubdivision(B)ofthissubdivision(1),a | |
| 39 | 85 | healthplanshallnotimposeanypriorauthorizationrequirementforany | |
| 40 | 86 | admission,item,service,treatment,orprocedureorderedbyaprimarycare | |
| 41 | 87 | provider. | |
| 42 | 88 | (B)Theprohibitionsetforthinsubdivision(A)ofthissubdivision | |
| 43 | 89 | (1)shallnotbeconstruedtoprohibitpriorauthorizationrequirementsfor | |
| 44 | 90 | prescriptiondrugsorforanadmission,item,service,treatment,orprocedure | |
| 45 | 91 | thatisprovidedout-of-network. | |
| 46 | 92 | (2)Asusedinthissubsection,“primarycareprovider”hasthesame | |
| 47 | 93 | meaningasisusedbytheVermontBlueprintforHealthmeansahealthcare | |
| 48 | 94 | providerwhoiscontractedandenrolledwiththehealthplanasaprimarycare | |
| 49 | 95 | provider. | |
| 50 | - | * * * No. 3 Page 3 of 3 | |
| 51 | - | 2025 | |
| 52 | - | ||
| 53 | - | VT LEG #381459 v.1 | |
| 96 | + | *** | |
| 54 | 97 | Sec.3.EFFECTIVEDATES | |
| 55 | 98 | (a)Sec.1(18V.S.A.§9418a)shalltakeeffectonJanuary1,2026. | |
| 56 | - | (b) | |
| 99 | + | (b)Sec.2(18V.S.A.§ 9418b)shalltakeeffectonpassageandshallbe | |
| 57 | 100 | implementedbyallhealthplansassoonasreasonablypracticableafterthat | |
| 58 | 101 | date,butinnoeventlaterthanJanuary1,2026. | |
| 59 | 102 | (c)Thissectionshalltakeeffectonpassage. | |
| 60 | - | Date Governor signed bill: March 5, 2025 | |
| 103 | + | 1 | |
| 104 | + | 2 | |
| 105 | + | 3 | |
| 106 | + | 4 | |
| 107 | + | 5 | |
| 108 | + | 6 | |
| 109 | + | 7 | |
| 110 | + | 8 | |
| 111 | + | 9 | |
| 112 | + | 10 | |
| 113 | + | 11 | |
| 114 | + | 12 | |
| 115 | + | 13 | |
| 116 | + | 14 | |
| 117 | + | 15 | |
| 118 | + | 16 | |
| 119 | + | 17 | |
| 120 | + | 18 | |
| 121 | + | 19 | |
| 122 | + | 20 |