Bill > SB897

This bill introduces new regulations for prior authorization in health care services, focusing on reducing administrative burdens for healthcare providers. Specifically, the bill prevents health carriers (insurance companies) or utilization review entities from requiring prior authorization for health care services if the provider has a high approval rate of 90% or more during a six-month evaluation period. The bill mandates that carriers notify providers within 25 days after an evaluation period about any prior authorization requirements, establish an appeals process, and maintain an online portal with detailed authorization information. Additionally, the bill prohibits denying or reducing payment to a provider with prior authorization unless the provider has knowingly misrepresented the service or failed to substantially perform it. The regulations do not apply to MO HealthNet (Medicaid) directly, though Medicaid managed care organizations are included, and they do not apply to providers who have not participated in a health plan for at least one full evaluation period. The bill also clarifies that providers cannot perform services outside their licensed scope and that carriers are not required to pay for such services.

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https://www.senate.mo.gov/26info/BTS_Web/Bill.aspx?SessionType=R&BillID=252