Bill > HB1976

This bill creates provisions relating to prior authorization of health care services. Specifically, it states that a health carrier or utilization review entity cannot require a health care provider to obtain prior authorization for a health care service unless the carrier or entity has approved less than 90% of the provider's prior authorization requests for that service or all services in the most recent evaluation period (first or last 6 months of the calendar year). The bill also requires the carrier or entity to notify providers of any such determinations, establish an appeals process, and maintain an online portal for providers to access prior authorization decisions. Additionally, the bill prohibits carriers or entities from denying or reducing payment for a service with prior authorization, except in cases of fraud or failure to substantially perform the service. The provisions do not apply to MO HealthNet (Medicaid) or providers who have not participated in the health benefit plan for at least one full evaluation period.