The bill amends the Prior Authorization Transparency Act by exempting certain healthcare providers from prior authorization requirements for specific services during a designated exemption period from January 1, 2024, to June 30, 2024. This exemption can be evaluated by healthcare insurers based on claims submitted during this timeframe, with criteria established for maintaining or rescinding the exemption. The bill also updates definitions related to healthcare insurers and introduces new terms, while mandating that utilization review entities publicly disclose their prior authorization requirements and allow healthcare providers to discuss treatment plans with licensed physicians before any adverse determinations are made.

Additionally, the bill enhances the appeal process for healthcare providers facing adverse determinations regarding prior authorization exemptions. Key provisions include requirements for providers to submit specific information for independent reviews, the ability to designate preferred communication methods, and a clear process for submitting appeals. Insurers are prohibited from retroactively denying services based on rescinded exemptions if the independent review organization does not affirm their decision. The bill also outlines insurers' responsibilities in evaluations and reviews, including providing detailed information when denying exemptions and covering costs for independent reviews, while establishing that providers who fail to provide medical records within a specified timeframe are ineligible for independent review. Overall, the legislation aims to improve transparency and fairness in the prior authorization process.

Statutes affected:
SB 143: 23-99-1103(8), 23-99-1103, 23-99-1104(a), 23-99-1111