Bill > HB3010

This bill establishes new regulations for health carriers, which are insurance companies or other entities that provide health benefits, regarding the process of prior authorization, a requirement for approval before certain medical services are provided. Key provisions include setting strict timeframes for health carriers to make utilization review decisions, with specific deadlines for notifying enrollees and providers of approvals or denials, and requiring written explanations for adverse determinations, including the clinical rationale used. The bill also extends the validity of prior authorization approvals for recurring services for chronic conditions to at least six months or the length of treatment, whichever is shorter, and mandates that if a health carrier fails to meet these deadlines, the service will be automatically deemed authorized. Furthermore, it requires health carriers to implement electronic systems for prior authorization requests, including an application programming interface (API) for health care services by 2027, and to publish statistics on their approval and denial rates. The bill also introduces a system where providers who consistently have a high approval rate for prior authorization requests may be exempted from this requirement, with provisions for auditing and rescinding exemptions if approval rates fall below 90%. Finally, it clarifies that health carriers cannot deny payment for a prior authorized service unless the provider misrepresented the service or failed to perform it, and it includes provisions for continuing prior authorizations when a patient switches health carriers.