Bill > S315

This bill introduces comprehensive reforms to utilization review (UR) processes in health insurance, aimed at increasing transparency and efficiency. The bill defines new terms like "urgent health care service" and establishes specific time lines for insurers to complete utilization reviews, requiring determinations within three business days for non-urgent services and within 24 hours for urgent services. It mandates detailed notification procedures for service approvals and denials, and introduces rigorous requirements for appeal reviews, including provisions that appeal reviewers must be medical professionals with specific qualifications and no conflicts of interest. The bill also requires insurers to provide clear information about utilization review procedures in coverage handbooks, membership cards, and websites, and mandates that any new UR requirements be publicly accessible before implementation. Notably, the bill prohibits insurers from using artificial intelligence as the sole basis for denying healthcare services and ensures that prior authorizations remain valid for certain periods, such as 90 days when a person switches health plans or six months for chronic condition treatments. The legislation will become effective October 1, 2026, and applies to insurance contracts issued or renewed after that date, with the State Health Plan for Teachers and State Employees required to review and align its practices accordingly.

https://www.ncleg.gov/BillLookUp/2025/S315