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Bill Detail: HB19-1211

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Title Prior Authorization Requirements Health Care Service
Status Introduced In House - Assigned to Health & Insurance (02/25/2019)
Bill Subjects
  • Health Care & Health Insurance
House Sponsors D. Michaelson Jenet (D)
Y. Caraveo (D)
Senate Sponsors A. Williams (D)
House Committee Health and Insurance
Senate Committee
Date Introduced 02/25/2019
Description

With regard to the prior authorization process used by carriers or
private utilization review organizations (organizations) acting on behalf
of carriers to review and determine whether a particular health care
service prescribed by a health care provider is approved as a covered
benefit under the patient's health benefit plan, the bill requires carriers

and organizations to:
  • Publish and update their prior authorization requirements
and restrictions;
  • Comply with deadlines established in the bill for making a
determination on a prior authorization request;
  • Use current, clinically based prior authorization criteria that
are aligned with other quality initiatives of the carrier or
organization and with other carriers' and organizations'
prior authorization criteria for the same health care service;
  • Limit the use of prior authorization to providers whose
prescribing or ordering patterns differ significantly from
the patterns of their peers after adjusting for patient mix
and other relevant factors; and
  • Exempt from prior authorization providers with an 80%
approval rate of prior authorization requests over the
previous 12 months, and conduct annual reevaluation of a
provider's eligibility for the exemption.
If a carrier or organization fails to make a determination within the
time required or fails to apply prior authorization requirements or exempt
providers from prior authorization requirements, the request is deemed
approved.
An approved prior authorization request is valid for at least 180
days and continues for the duration of the prescribed or ordered course of
treatment and the covered person's plan year.
The commissioner of insurance is authorized to adopt rules as
necessary to implement the bill.

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with Amendments
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