HB2351 S H&HR AM #4

Dellinger  7965

 

The Committee on Health and Human Resources moved to amend the bill by striking out everything after the enacting clause and inserting in lieu thereof the following:

CHAPTER 5. GENERAL POWERS AND AUTHORITY OF THE GOVERNOR, SECRETARY OF STATE, AND ATTORNEY GENERAL; BOARD OF PUBLIC WORKS; MISCELLANEOUS AGENCIES, COMMISSIONS, OFFICES, PROGRAMS, ETC.

ARTICLE 16. WEST VIRGINIA PUBLIC EMPLOYEES INSURANCE ACT.

§5-16-7f. Prior authorization.

(a) As used in this section, the following words and phrases have the meanings given to them in this section unless the context clearly indicates otherwise:

(1) Episode of Care means a specific medical problem, condition, or specific illness being managed across a continuum of care and includes tests and procedures initially requested, excluding out of network care: Provided, That any additional testing or procedures unrelated to the specific medical problem, condition, or specific illness being managed will required a separate prior authorization.

(2) National Council for Prescription Drug Programs (NCPDP) SCRIPT Standard means the NCPDP SCRIPT Standard Version 201310 or the most recent standard adopted by the United States Department of Health and Human Services (HHS).  Subsequently released versions may be used provided that the new version is backward compatible with the current version approved by HHS;

(3) Prior Authorization means obtaining advance approval from a health insurer about the coverage of a service or medication.

(b)The health insurers are required to develop prior authorization forms and portals and shall accept one prior authorization for an episode of care. These forms are required to be placed in an easily identifiable and accessible place on their webpage. The forms shall:

(1) Include instructions for the submission of clinical documentation;

(2) Provide an electronic notification confirming receipt of the prior authorization request if forms are submitted electronically;

(3) Contain a comprehensive list of all procedures, services, drugs, devices, treatment, durable medical equipment, and anything else for which the health insurer requires prior authorization. This list shall also delineate those items which are bundled together as part of the episode of care.  The standard for including any matter on this list shall be science-based using a nationally recognized standard. This list is required to be updated regularly to ensure that the list remains current;

(4) Inform the patient if the health insurers require plan members to use step therapy protocols, as set forth in this chapter. This must be conspicuous on the prior authorization form.  If the patient has completed step therapy as required by the health insurer and the step therapy has been unsuccessful, this shall be clearly indicated on the form, including information regarding medication or therapies which were attempted and were unsuccessful; and

(5)  Be prepared by October 1, 2019.

(c) The health insurers shall accept electronic prior authorization requests and respond to the request through electronic means by July 1, 2020. The health insurer is required to accept an electronically submitted prior authorization and may not require more than one prior authorization form for an episode of care. If the health insurers are currently accepting electronic prior authorization requests, they shall have until January 1, 2020, to implement the provisions of this section.

(d) If the health care practitioner submits the request for prior authorization electronically, and all of the information as required is provided, the health insurer shall respond to the prior authorization request within seven days from the time on the electronic receipt of the prior authorization request, except that the health insurer shall respond to the prior authorization request within two days if the request is for medical care or other service for a condition where application of the time frame for making routine or non-life-threatening care determinations is either of the following:

(1) Could seriously jeopardize the life, health, or safety of the patient or others due to the patient’s psychological state; or

(2) In the opinion of a practitioner with knowledge of the patient’s medical or behavioral condition, would subject the patient to adverse health consequences without the care or treatment that is the subject of the request.

(e) If information submitted is considered incomplete, the health insurer shall identify all deficiencies and within two business days return the prior authorization to the health care practitioner. The health care practitioner shall provide the additional information requested within three business days from the time the request is received by the practitioner or the prior authorization is deemed denied and a new request must be submitted.

(f) If the health insurer wishes to audit the prior authorization or if the information regarding step therapy is incomplete, the prior authorization may be transferred to the peer review process.

(g) A prior authorization approved by a managed care organization is carried over to all other managed care organizations for three months if the services are provided within the state.

(h) The health insurers shall use national best practice guidelines to evaluate a prior authorization.

(i) If a prior authorization is rejected by the health insurer and the health care practitioner who submitted the prior authorization requests a peer review of the decision to reject, the peer review shall be with a health care practitioner similar in specialty, education, and background. The health insurer’s medical director has the ultimate decision regarding the appeal determination and the health care practitioner has the option to consult with the medical director after the peer-to- peer consultation.  Time frames regarding this appeal process shall take no longer than 30 days.

(j) Any inpatient prescription written at the time of discharge requiring a prior authorization shall not be subject to prior authorization requirements and shall be immediately approved for not less than three days:  Provided, That the cost of the medication does not exceed $5,000 per day and the physician shall note on the prescription or notify the pharmacy that the prescription is being provided at discharge. After the three-day time frame, a prior authorization must be obtained.

(k) If the approval of a prior authorization requires a medication substitution, the substituted medication must be of an equivalent medication class. 

(l) In the event a health care practitioner has performed an average of 30 procedures per year and in a six-month time period has received a 100 percent prior approval rating, the health insurer shall not require the health care practitioner to submit a prior authorization for that procedure for the next six months.  At the end of the six-month time frame, the exemption will be reviewed prior to renewal.  This exemption is subject to internal auditing by the health insurer at any time and may be rescinded if the health insurer determines the health care practitioner is not performing the procedure in conformity with the health insurer’s benefit plan based upon the results of the health insurer’s internal audit.

(m) The health insurers must accept and respond to prior authorization requests for pharmacy benefits by July 1, 2020, or if the health insurers are currently accepting electronic prior authorization requests, it shall have until January 1, 2020, to implement this provision.  The health insurers shall accept and respond to prior authorizations though a secure electronic transmission using the NCPDP SCRIPT Standard ePA transactions.

 (n) This section is effective for policy, contract, plans, or agreements beginning on or after January 1, 2020. This section applies to all policies, contracts, plans, or agreements, subject to this article, that are delivered, executed, issued, amended, adjusted, or renewed in this state on or after the effective date of this section.

(o) The Department of Health and Human Services shall have sole authority to enforce the provisions of this section as it relates to medical services paid for by managed care organizations pursuant to a contract with the department to provide medical services: Provided That the requirements in this subsection shall be expressly memorialized in such contract.

(p) The timeframes in this section are not applicable to prior authorization requests submitted through telephone, mail, or fax.


Chapter 33. Insurance.

ARTICLE 15. accident and sickness insurance.

§33-15-4s. Prior authorization.

(a) As used in this section, the following words and phrases have the meanings given to them in this section unless the context clearly indicates otherwise:

(1) Episode of Care means a specific medical problem, condition, or specific illness being managed across a continuum of care and includes tests and procedures initially requested, excluding out of network care: Provided, That any additional testing or procedures unrelated to the specific medical problem, condition, or specific illness being managed will required a separate prior authorization.

(2) National Council for Prescription Drug Programs (NCPDP) SCRIPT Standard means the NCPDP SCRIPT Standard Version 201310 or the most recent standard adopted by the United States Department of Health and Human Services (HHS).  Subsequently released versions may be used provided that the new version is backward compatible with the current version approved by HHS;

(3) Prior Authorization means obtaining advance approval from a health insurer about the coverage of a service or medication.

(b)The health insurers are required to develop prior authorization forms and portals and shall accept one prior authorization for an episode of care. These forms are required to be placed in an easily identifiable and accessible place on their webpage. The forms shall:

(1) Include instructions for the submission of clinical documentation;

(2) Provide an electronic notification confirming receipt of the prior authorization request if forms are submitted electronically;

(3) Contain a comprehensive list of all procedures, services, drugs, devices, treatment, durable medical equipment, and anything else for which the health insurer requires prior authorization. This list shall also delineate those items which are bundled together as part of the episode of care.  The standard for including any matter on this list shall be science-based using a nationally recognized standard. This list is required to be updated regularly to ensure that the list remains current;

(4) Inform the patient if the health insurers require plan members to use step therapy protocols, as set forth in this chapter. This must be conspicuous on the prior authorization form.  If the patient has completed step therapy as required by the health insurer and the step therapy has been unsuccessful, this shall be clearly indicated on the form, including information regarding medication or therapies which were attempted and were unsuccessful; and

(5)  Be prepared by October 1, 2019.

(c) The health insurers shall accept electronic prior authorization requests and respond to the request through electronic means by July 1, 2020. The health insurer is required to accept an electronically submitted prior authorization and may not require more than one prior authorization form for an episode of care. If the health insurers are currently accepting electronic prior authorization requests, they shall have until January 1, 2020, to implement the provisions of this section.

(d) If the health care practitioner submits the request for prior authorization electronically, and all of the information as required is provided, the health insurer shall respond to the prior authorization request within seven days from the time on the electronic receipt of the prior authorization request, except that the health insurer shall respond to the prior authorization request within two days if the request is for medical care or other service for a condition where application of the time frame for making routine or non-life-threatening care determinations is either of the following:

(1) Could seriously jeopardize the life, health, or safety of the patient or others due to the patient’s psychological state; or

(2) In the opinion of a practitioner with knowledge of the patient’s medical or behavioral condition, would subject the patient to adverse health consequences without the care or treatment that is the subject of the request.

(e) If information submitted is considered incomplete, the health insurer shall identify all deficiencies and within two business days return the prior authorization to the health care practitioner. The health care practitioner shall provide the additional information requested within three business days from the time the request is received by the practitioner or the prior authorization is deemed denied and a new request must be submitted.

(f) If the health insurer wishes to audit the prior authorization or if the information regarding step therapy is incomplete, the prior authorization may be transferred to the peer review process.

(g) A prior authorization approved by a managed care organization is carried over to all other managed care organizations for three months if the services are provided within the state.

(h) The health insurers shall use national best practice guidelines to evaluate a prior authorization.

(i) If a prior authorization is rejected by the health insurer and the health care practitioner who submitted the prior authorization requests a peer review of the decision to reject, the peer review shall be with a health care practitioner similar in specialty, education, and background. The health insurer’s medical director has the ultimate decision regarding the appeal determination and the health care practitioner has the option to consult with the medical director after the peer-to- peer consultation.  Time frames regarding this appeal process shall take no longer than 30 days.

(j) Any inpatient prescription written at the time of discharge requiring a prior authorization shall not be subject to prior authorization requirements and shall be immediately approved for not less than three days:  Provided, That the cost of the medication does not exceed $5,000 per day and the physician shall note on the prescription or notify the pharmacy that the prescription is being provided at discharge. After the three-day time frame, a prior authorization must be obtained.

(k) If the approval of a prior authorization requires a medication substitution, the substituted medication must be of an equivalent medication class. 

(l) In the event a health care practitioner has performed an average of 30 procedures per year and in a six-month time period has received a 100 percent prior approval rating, the health insurer shall not require the health care practitioner to submit a prior authorization for that procedure for the next six months.  At the end of the six-month time frame, the exemption will be reviewed prior to renewal.  This exemption is subject to internal auditing by the health insurer at any time and may be rescinded if the health insurer determines the health care practitioner is not performing the procedure in conformity with the health insurer’s benefit plan based upon the results of the health insurer’s internal audit.

(m) The health insurers must accept and respond to prior authorization requests for pharmacy benefits by July 1, 2020, or if the health insurers are currently accepting electronic prior authorization requests, it shall have until January 1, 2020, to implement this provision.  The health insurers shall accept and respond to prior authorizations though a secure electronic transmission using the NCPDP SCRIPT Standard ePA transactions.

 (n) This section is effective for policy, contract, plans, or agreements beginning on or after January 1, 2020. This section applies to all policies, contracts, plans, or agreements, subject to this article, that are delivered, executed, issued, amended, adjusted, or renewed in this state on or after the effective date of this section.

(o) The Department of Health and Human Services shall have sole authority to enforce the provisions of this section as it relates to medical services paid for by managed care organizations pursuant to a contract with the department to provide medical services: Provided, That the requirements in this subsection shall be expressly memorialized in such contract.

(p) The timeframes in this section are not applicable to prior authorization requests submitted through telephone, mail, or fax.

ARTICLE 16. Group accident and sickness inSURANCE.

§33-16-3dd. Prior authorization.


(a) As used in this section, the following words and phrases have the meanings given to them in this section unless the context clearly indicates otherwise:

(1) Episode of Care means a specific medical problem, condition, or specific illness being managed across a continuum of care and includes tests and procedures initially requested, excluding out of network care: Provided, That any additional testing or procedures unrelated to the specific medical problem, condition, or specific illness being managed will required a separate prior authorization.

(2) National Council for Prescription Drug Programs (NCPDP) SCRIPT Standard means the NCPDP SCRIPT Standard Version 201310 or the most recent standard adopted by the United States Department of Health and Human Services (HHS).  Subsequently released versions may be used provided that the new version is backward compatible with the current version approved by HHS;

(3) Prior Authorization means obtaining advance approval from a health insurer about the coverage of a service or medication.

(b)The health insurers are required to develop prior authorization forms and portals and shall accept one prior authorization for an episode of care. These forms are required to be placed in an easily identifiable and accessible place on their webpage. The forms shall:

(1) Include instructions for the submission of clinical documentation;

(2) Provide an electronic notification confirming receipt of the prior authorization request if forms are submitted electronically;

(3) Contain a comprehensive list of all procedures, services, drugs, devices, treatment, durable medical equipment, and anything else for which the health insurer requires prior authorization. This list shall also delineate those items which are bundled together as part of the episode of care.  The standard for including any matter on this list shall be science-based using a nationally recognized standard. This list is required to be updated regularly to ensure that the list remains current;

(4) Inform the patient if the health insurers require plan members to use step therapy protocols, as set forth in this chapter. This must be conspicuous on the prior authorization form.  If the patient has completed step therapy as required by the health insurer and the step therapy has been unsuccessful, this shall be clearly indicated on the form, including information regarding medication or therapies which were attempted and were unsuccessful; and

(5)  Be prepared by October 1, 2019.

(c) The health insurers shall accept electronic prior authorization requests and respond to the request through electronic means by July 1, 2020. The health insurer is required to accept an electronically submitted prior authorization and may not require more than one prior authorization form for an episode of care. If the health insurers are currently accepting electronic prior authorization requests, they shall have until January 1, 2020, to implement the provisions of this section.

(d) If the health care practitioner submits the request for prior authorization electronically, and all of the information as required is provided, the health insurer shall respond to the prior authorization request within seven days from the time on the electronic receipt of the prior authorization request, except that the health insurer shall respond to the prior authorization request within two days if the request is for medical care or other service for a condition where application of the time frame for making routine or non-life-threatening care determinations is either of the following:

(1) Could seriously jeopardize the life, health, or safety of the patient or others due to the patient’s psychological state; or

(2) In the opinion of a practitioner with knowledge of the patient’s medical or behavioral condition, would subject the patient to adverse health consequences without the care or treatment that is the subject of the request.

(e) If information submitted is considered incomplete, the health insurer shall identify all deficiencies and within two business days return the prior authorization to the health care practitioner. The health care practitioner shall provide the additional information requested within three business days from the time the request is received by the practitioner or the prior authorization is deemed denied and a new request must be submitted.

(f) If the health insurer wishes to audit the prior authorization or if the information regarding step therapy is incomplete, the prior authorization may be transferred to the peer review process.

(g) A prior authorization approved by a managed care organization is carried over to all other managed care organizations for three months if the services are provided within the state.

(h) The health insurers shall use national best practice guidelines to evaluate a prior authorization.

(i) If a prior authorization is rejected by the health insurer and the health care practitioner who submitted the prior authorization requests a peer review of the decision to reject, the peer review shall be with a health care practitioner similar in specialty, education, and background. The health insurer’s medical director has the ultimate decision regarding the appeal determination and the health care practitioner has the option to consult with the medical director after the peer-to- peer consultation.  Time frames regarding this appeal process shall take no longer than 30 days.

(j) Any inpatient prescription written at the time of discharge requiring a prior authorization shall not be subject to prior authorization requirements and shall be immediately approved for not less than three days:  Provided, That the cost of the medication does not exceed $5,000 per day and the physician shall note on the prescription or notify the pharmacy that the prescription is being provided at discharge. After the three-day time frame, a prior authorization must be obtained.

(k) If the approval of a prior authorization requires a medication substitution, the substituted medication must be of an equivalent medication class. 

(l) In the event a health care practitioner has performed an average of 30 procedures per year and in a six-month time period has received a 100 percent prior approval rating, the health insurer shall not require the health care practitioner to submit a prior authorization for that procedure for the next six months.  At the end of the six-month time frame, the exemption will be reviewed prior to renewal.  This exemption is subject to internal auditing by the health insurer at any time and may be rescinded if the health insurer determines the health care practitioner is not performing the procedure in conformity with the health insurer’s benefit plan based upon the results of the health insurer’s internal audit.

(m) The health insurers must accept and respond to prior authorization requests for pharmacy benefits by July 1, 2020, or if the health insurers are currently accepting electronic prior authorization requests, it shall have until January 1, 2020, to implement this provision.  The health insurers shall accept and respond to prior authorizations though a secure electronic transmission using the NCPDP SCRIPT Standard ePA transactions.

 (n) This section is effective for policy, contract, plans, or agreements beginning on or after January 1, 2020. This section applies to all policies, contracts, plans, or agreements, subject to this article, that are delivered, executed, issued, amended, adjusted, or renewed in this state on or after the effective date of this section.

(o) The Department of Health and Human Services shall have sole authority to enforce the provisions of this section as it relates to medical services paid for by managed care organizations pursuant to a contract with the department to provide medical services: Provided, That the requirements in this subsection shall be expressly memorialized in such contract.

(p) The timeframes in this section are not applicable to prior authorization requests submitted through telephone, mail, or fax.

ARTICLE 24. HOSPITAL SERVICE CORPORATIONS, MEDICAL SERVICE CORPORATIONS, DENTAL SERVICE CORPORATIONS, AND HEALTH SERVICE CORPORATIONS.

§33-24-7s. Prior authorization.

(a) As used in this section, the following words and phrases have the meanings given to them in this section unless the context clearly indicates otherwise:

(1) Episode of Care means a specific medical problem, condition, or specific illness being managed across a continuum of care and includes tests and procedures initially requested, excluding out of network care; Provided, That any additional testing or procedures unrelated to the specific medical problem, condition, or specific illness being managed will required a separate prior authorization.

(2) National Council for Prescription Drug Programs (NCPDP) SCRIPT Standard means the NCPDP SCRIPT Standard Version 201310 or the most recent standard adopted by the United States Department of Health and Human Services (HHS).  Subsequently released versions may be used provided that the new version is backward compatible with the current version approved by HHS;

(3) Prior Authorization means obtaining advance approval from a health insurer about the coverage of a service or medication.

(b)The health insurers are required to develop prior authorization forms and portals and shall accept one prior authorization for an episode of care. These forms are required to be placed in an easily identifiable and accessible place on their webpage. The forms shall:

(1) Include instructions for the submission of clinical documentation;

(2) Provide an electronic notification confirming receipt of the prior authorization request if forms are submitted electronically;

(3) Contain a comprehensive list of all procedures, services, drugs, devices, treatment, durable medical equipment and anything else for which the health insurer requires prior authorization. This list shall also delineate those items which are bundled together as part of the episode of care.  The standard for including any matter on this list shall be science-based using a nationally recognized standard. This list is required to be updated regularly to ensure that the list remains current;

(4) Inform the patient if the health insurers require plan members to use step therapy protocols, as set forth in this chapter. This must be conspicuous on the prior authorization form.  If the patient has completed step therapy as required by the health insurer and the step therapy has been unsuccessful, this shall be clearly indicated on the form, including information regarding medication or therapies which were attempted and were unsuccessful; and

(5)  Be prepared by October 1, 2019.

(c) The health insurers shall accept electronic prior authorization requests and respond to the request through electronic means by July 1, 2020. The health insurer is required to accept an electronically submitted prior authorization and may not require more than one prior authorization form for an episode of care. If the health insurers are currently accepting electronic prior authorization requests, they shall have until January 1, 2020, to implement the provisions of this section.

(d) If the health care practitioner submits the request for prior authorization electronically, and all of the information as required is provided, the health insurer shall respond to the prior authorization request within seven days from the time on the electronic receipt of the prior authorization request, except that the health insurer shall respond to the prior authorization request within two days if the request is for medical care or other service for a condition where application of the time frame for making routine or non-life-threatening care determinations is either of the following:

(1) Could seriously jeopardize the life, health, or safety of the patient or others due to the patient’s psychological state; or

(2) In the opinion of a practitioner with knowledge of the patient’s medical or behavioral condition, would subject the patient to adverse health consequences without the care or treatment that is the subject of the request.

(e) If information submitted is considered incomplete, the health insurer shall identify all deficiencies and within two business days return the prior authorization to the health care practitioner. The health care practitioner shall provide the additional information requested within three business days from the time the request is received by the practitioner or the prior authorization is deemed denied and a new request must be submitted.

(f) If the health insurer wishes to audit the prior authorization or if the information regarding step therapy is incomplete, the prior authorization may be transferred to the peer review process.

(g) A prior authorization approved by a managed care organization is carried over to all other managed care organizations for three months if the services are provided within the state.

(h) The health insurers shall use national best practice guidelines to evaluate a prior authorization.

(i) If a prior authorization is rejected by the health insurer and the health care practitioner who submitted the prior authorization requests a peer review of the decision to reject, the peer review shall be with a health care practitioner similar in specialty, education, and background. The health insurer’s medical director has the ultimate decision regarding the appeal determination and the health care practitioner has the option to consult with the medical director after the peer-to-peer consultation.  Time frames regarding this appeal process shall take no longer than 30 days.

(j) Any inpatient prescription written at the time of discharge requiring a prior authorization shall not be subject to prior authorization requirements and shall be immediately approved for not less than three days:  Provided, That the cost of the medication does not exceed $5,000 per day and the physician shall note on the prescription or notify the pharmacy that the prescription is being provided at discharge. After the three-day time frame, a prior authorization must be obtained.

(k) If the approval of a prior authorization requires a medication substitution, the substituted medication must be of an equivalent medication class. 

(l) In the event a health care practitioner has performed an average of 30 procedures per year and in a six-month time period has received a 100 percent prior approval rating, the health insurer shall not require the health care practitioner to submit a prior authorization for that procedure for the next six months.  At the end of the six-month time frame, the exemption will be reviewed prior to renewal.  This exemption is subject to internal auditing by the health insurer at any time and may be rescinded if the health insurer determines the health care practitioner is not performing the procedure in conformity with the health insurer’s benefit plan based upon the results of the health insurer’s internal audit.

(m) The health insurers must accept and respond to prior authorization requests for pharmacy benefits by July 1, 2020, or if the health insurers are currently accepting electronic prior authorization requests, it shall have until January 1, 2020, to implement this provision.  The health insurers shall accept and respond to prior authorizations though a secure electronic transmission using the NCPDP SCRIPT Standard ePA transactions.

 (n) This section is effective for policy, contract, plans, or agreements beginning on or after January 1, 2020. This section applies to all policies, contracts, plans, or agreements, subject to this article, that are delivered, executed, issued, amended, adjusted, or renewed in this state on or after the effective date of this section.

(o) The Department of Health and Human Services shall have sole authority to enforce the provisions of this section as it relates to medical services paid for by managed care organizations pursuant to a contract with the department to provide medical services: Provided, That the requirements in this subsection shall be expressly memorialized in such contract.

(p) The timeframes in this section are not applicable to prior authorization requests submitted through telephone, mail, or fax.


ARTICLE 25. Health Care Corporations.

§33-25-8p. Prior authorization.

(a) As used in this section, the following words and phrases have the meanings given to them in this section unless the context clearly indicates otherwise:

(1) Episode of Care means a specific medical problem, condition, or specific illness being managed across a continuum of care and includes tests and procedures initially requested, excluding out of network care: Provided, That any additional testing or procedures unrelated to the specific medical problem, condition, or specific illness being managed will required a separate prior authorization.

(2) National Council for Prescription Drug Programs (NCPDP) SCRIPT Standard means the NCPDP SCRIPT Standard Version 201310 or the most recent standard adopted by the United States Department of Health and Human Services (HHS).  Subsequently released versions may be used provided that the new version is backward compatible with the current version approved by HHS;

(3) Prior Authorization means obtaining advance approval from a health insurer about the coverage of a service or medication.

(b)The health insurers are required to develop prior authorization forms and portals and shall accept one prior authorization for an episode of care. These forms are required to be placed in an easily identifiable and accessible place on their webpage. The forms shall:

(1) Include instructions for the submission of clinical documentation;

(2) Provide an electronic notification confirming receipt of the prior authorization request if forms are submitted electronically;

(3) Contain a comprehensive list of all procedures, services, drugs, devices, treatment, durable medical equipment, and anything else for which the health insurer requires prior authorization. This list shall also delineate those items which are bundled together as part of the episode of care.  The standard for including any matter on this list shall be science-based using a nationally recognized standard. This list is required to be updated regularly to ensure that the list remains current;

(4) Inform the patient if the health insurers require plan members to use step therapy protocols, as set forth in this chapter. This must be conspicuous on the prior authorization form.  If the patient has completed step therapy as required by the health insurer and the step therapy has been unsuccessful, this shall be clearly indicated on the form, including information regarding medication or therapies which were attempted and were unsuccessful; and

(5)  Be prepared by October 1, 2019.

(c) The health insurers shall accept electronic prior authorization requests and respond to the request through electronic means by July 1, 2020. The health insurer is required to accept an electronically submitted prior authorization and may not require more than one prior authorization form for an episode of care. If the health insurers are currently accepting electronic prior authorization requests, they shall have until January 1, 2020, to implement the provisions of this section.

(d) If the health care practitioner submits the request for prior authorization electronically, and all of the information as required is provided, the health insurer shall respond to the prior authorization request within seven days from the time on the electronic receipt of the prior authorization request, except that the health insurer shall respond to the prior authorization request within two days if the request is for medical care or other service for a condition where application of the time frame for making routine or non-life-threatening care determinations is either of the following:

(1) Could seriously jeopardize the life, health, or safety of the patient or others due to the patient’s psychological state; or

(2) In the opinion of a practitioner with knowledge of the patient’s medical or behavioral condition, would subject the patient to adverse health consequences without the care or treatment that is the subject of the request.

(e) If information submitted is considered incomplete, the health insurer shall identify all deficiencies and within two business days return the prior authorization to the health care practitioner. The health care practitioner shall provide the additional information requested within three business days from the time the request is received by the practitioner or the prior authorization is deemed denied and a new request must be submitted.

(f) If the health insurer wishes to audit the prior authorization or if the information regarding step therapy is incomplete, the prior authorization may be transferred to the peer review process.

(g) A prior authorization approved by a managed care organization is carried over to all other managed care organizations for three months if the services are provided within the state.

(h) The health insurers shall use national best practice guidelines to evaluate a prior authorization.

(i) If a prior authorization is rejected by the health insurer and the health care practitioner who submitted the prior authorization requests a peer review of the decision to reject, the peer review shall be with a health care practitioner similar in specialty, education, and background. The health insurer’s medical director has the ultimate decision regarding the appeal determination and the health care practitioner has the option to consult with the medical director after the peer-to-peer consultation.  Time frames regarding this appeal process shall take no longer than 30 days.

(j) Any inpatient prescription written at the time of discharge requiring a prior authorization shall not be subject to prior authorization requirements and shall be immediately approved for not less than three days:  Provided, That the cost of the medication does not exceed $5,000 per day and the physician shall note on the prescription or notify the pharmacy that the prescription is being provided at discharge. After the three-day time frame, a prior authorization must be obtained.

(k) If the approval of a prior authorization requires a medication substitution, the substituted medication must be of an equivalent medication class. 

(l) In the event a health care practitioner has performed an average of 30 procedures per year and in a six-month time period has received a 100 percent prior approval rating, the health insurer shall not require the health care practitioner to submit a prior authorization for that procedure for the next six months.  At the end of the six-month time frame, the exemption will be reviewed prior to renewal.  This exemption is subject to internal auditing by the health insurer at any time and may be rescinded if the health insurer determines the health care practitioner is not performing the procedure in conformity with the health insurer’s benefit plan based upon the results of the health insurer’s internal audit.

(m) The health insurers must accept and respond to prior authorization requests for pharmacy benefits by July 1, 2020, or if the health insurers are currently accepting electronic prior authorization requests, it shall have until January 1, 2020, to implement this provision.  The health insurers shall accept and respond to prior authorizations though a secure electronic transmission using the NCPDP SCRIPT Standard ePA transactions.

 (n) This section is effective for policy, contract, plans, or agreements beginning on or after January 1, 2020. This section applies to all policies, contracts, plans, or agreements, subject to this article, that are delivered, executed, issued, amended, adjusted, or renewed in this state on or after the effective date of this section.

(o) The Department of Health and Human Services shall have sole authority to enforce the provisions of this section as it relates to medical services paid for by managed care organizations pursuant to a contract with the department to provide medical services: Provided, That the requirements in this subsection shall be expressly memorialized in such contract.

(p) The timeframes in this section are not applicable to prior authorization requests submitted through telephone, mail, or fax.


ARTICLE 25A. Health Maintenance Organization Act.

§33-25A-8s. Prior authorization.

(a) As used in this section, the following words and phrases have the meanings given to them in this section unless the context clearly indicates otherwise:

(1) Episode of Care means a specific medical problem, condition, or specific illness being managed across a continuum of care and includes tests and procedures initially requested, excluding out of network care: Provided, That any additional testing or procedures unrelated to the specific medical problem, condition, or specific illness being managed will required a separate prior authorization.

(2) National Council for Prescription Drug Programs (NCPDP) SCRIPT Standard means the NCPDP SCRIPT Standard Version 201310 or the most recent standard adopted by the United States Department of Health and Human Services (HHS).  Subsequently released versions may be used provided that the new version is backward compatible with the current version approved by HHS;

(3) Prior Authorization means obtaining advance approval from a health insurer about the coverage of a service or medication.

(b)The health insurers are required to develop prior authorization forms and portals and shall accept one prior authorization for an episode of care. These forms are required to be placed in an easily identifiable and accessible place on their webpage. The forms shall:

(1) Include instructions for the submission of clinical documentation;

(2) Provide an electronic notification confirming receipt of the prior authorization request if forms are submitted electronically;

(3) Contain a comprehensive list of all procedures, services, drugs, devices, treatment, durable medical equipment, and anything else for which the health insurer requires prior authorization. This list shall also delineate those items which are bundled together as part of the episode of care.  The standard for including any matter on this list shall be science-based using a nationally recognized standard. This list is required to be updated regularly to ensure that the list remains current;

(4) Inform the patient if the health insurers require plan members to use step therapy protocols, as set forth in this chapter. This must be conspicuous on the prior authorization form.  If the patient has completed step therapy as required by the health insurer and the step therapy has been unsuccessful, this shall be clearly indicated on the form, including information regarding medication or therapies which were attempted and were unsuccessful; and

(5)  Be prepared by October 1, 2019.

(c) The health insurers shall accept electronic prior authorization requests and respond to the request through electronic means by July 1, 2020. The health insurer is required to accept an electronically submitted prior authorization and may not require more than one prior authorization form for an episode of care. If the health insurers are currently accepting electronic prior authorization requests, they shall have until January 1, 2020, to implement the provisions of this section.

(d) If the health care practitioner submits the request for prior authorization electronically, and all of the information as required is provided, the health insurer shall respond to the prior authorization request within seven days from the time on the electronic receipt of the prior authorization request, except that the health insurer shall respond to the prior authorization request within two days if the request is for medical care or other service for a condition where application of the time frame for making routine or non-life-threatening care determinations is either of the following:

(1) Could seriously jeopardize the life, health, or safety of the patient or others due to the patient’s psychological state; or

(2) In the opinion of a practitioner with knowledge of the patient’s medical or behavioral condition, would subject the patient to adverse health consequences without the care or treatment that is the subject of the request.

(e) If information submitted is considered incomplete, the health insurer shall identify all deficiencies and within two business days return the prior authorization to the health care practitioner. The health care practitioner shall provide the additional information requested within three business days from the time the request is received by the practitioner or the prior authorization is deemed denied and a new request must be submitted.

(f) If the health insurer wishes to audit the prior authorization or if the information regarding step therapy is incomplete, the prior authorization may be transferred to the peer review process.

(g) A prior authorization approved by a managed care organization is carried over to all other managed care organizations for three months if the services are provided within the state.

(h) The health insurers shall use national best practice guidelines to evaluate a prior authorization.

(i) If a prior authorization is rejected by the health insurer and the health care practitioner who submitted the prior authorization requests a peer review of the decision to reject, the peer review shall be with a health care practitioner similar in specialty, education, and background. The health insurer’s medical director has the ultimate decision regarding the appeal determination and the health care practitioner has the option to consult with the medical director after the peer-to-peer consultation.  Time frames regarding this appeal process shall take no longer than 30 days.

(j) Any inpatient prescription written at the time of discharge requiring a prior authorization shall not be subject to prior authorization requirements and shall be immediately approved for not less than three days:  Provided, That the cost of the medication does not exceed $5,000 per day and the physician shall note on the prescription or notify the pharmacy that the prescription is being provided at discharge. After the three-day time frame, a prior authorization must be obtained.

(k) If the approval of a prior authorization requires a medication substitution, the substituted medication must be of an equivalent medication class. 

(l) In the event a health care practitioner has performed an average of 30 procedures per year and in a six-month time period has received a 100 percent prior approval rating, the health insurer shall not require the health care practitioner to submit a prior authorization for that procedure for the next six months.  At the end of the six-month time frame, the exemption will be reviewed prior to renewal.  This exemption is subject to internal auditing by the health insurer at any time and may be rescinded if the health insurer determines the health care practitioner is not performing the procedure in conformity with the health insurer’s benefit plan based upon the results of the health insurer’s internal audit.

(m) The health insurers must accept and respond to prior authorization requests for pharmacy benefits by July 1, 2020, or if the health insurers are currently accepting electronic prior authorization requests, it shall have until January 1, 2020, to implement this provision.  The health insurers shall accept and respond to prior authorizations though a secure electronic transmission using the NCPDP SCRIPT Standard ePA transactions.

 (n) This section is effective for policy, contract, plans, or agreements beginning on or after January 1, 2020. This section applies to all policies, contracts, plans, or agreements, subject to this article, that are delivered, executed, issued, amended, adjusted, or renewed in this state on or after the effective date of this section.

(o) The Department of Health and Human Services shall have sole authority to enforce the provisions of this section as it relates to medical services paid for by managed care organizations pursuant to a contract with the department to provide medical services: Provided That the requirements in this subsection shall be expressly memorialized in such contract.

(p) The timeframes in this section are not applicable to prior authorization requests submitted through telephone, mail, or fax.

 


 

Adopted

Rejected