Bill > HF2635

This bill aims to regulate health carriers, utilization review organizations (UROs), and certificate of need (CON) processes, with many provisions taking effect on January 1, 2027. It restricts UROs from solely using artificial intelligence (AI) to deny, delay, or downgrade prior authorization requests for health care services based on medical necessity, requiring human review for such decisions. The bill also establishes new rules for URO audits, mandating notification of audits within 15 days, determination within 45 days of receiving requested documentation, and a 30-day timeframe for appeals, with penalties for violations. It sets standards for health carrier conduct, prohibiting them from penalizing providers for out-of-network referrals or interfering with provider decisions on staffing and referrals, and requiring negotiation opportunities before enforcing agreements. For prior authorizations, the bill mandates that denials or downgrades must be made by a qualified reviewer or clinical peer, with detailed written explanations and appeal processes provided to providers and patients, and allows for consultations between providers and reviewers. It also exempts certain cancer screenings and emergency medical conditions from prior authorization requirements. The CON process is modified by increasing the cost thresholds for projects requiring a CON, adjusting fee structures, and streamlining review procedures, while also expanding the types of facilities and services subject to CON review, including specific behavioral health services, open heart surgery, organ transplantation, radiation therapy, and cardiac catheterization.

Health And Human Services (House)

https://www.legis.iowa.gov/legislation/BillBook?ga=91&ba=HF2635