Bill > SB230

This bill introduces new regulations for prior authorization in healthcare services, specifically targeting health carriers and utilization review entities. The bill defines an "evaluation period" as six-month segments of a calendar year and establishes that a health carrier cannot require prior authorization from a healthcare provider if that provider has been approved for at least 90% of their prior authorization requests during the most recent evaluation period. The bill mandates that health carriers provide notification to healthcare providers within 25 days after an evaluation period, detailing the statistical basis for any prior authorization requirements. Additionally, carriers must maintain an online portal for providers to track authorization decisions and establish an appeal process. The bill protects healthcare providers by preventing payment denials for services with prior authorization, unless the provider has knowingly misrepresented the service or failed to substantially perform it. The provisions do not apply to MO HealthNet (except for Medicaid managed care organizations) or to providers who have not participated in a health benefit plan for at least one full evaluation period. Importantly, the bill does not authorize providers to offer services outside their licensed scope and does not require carriers to pay for such services.

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https://www.senate.mo.gov/25info/BTS_Web/Bill.aspx?SessionType=R&BillID=333