This bill proposes updates to current statutes regarding the denial of claims and prior authorizations by health care insurers. Under the new provisions, before a health care insurer may deny a claim or issue a direct denial of a prior authorization based on medical necessity, the medical director must individually review the denial. During this review, the medical director is required to exercise independent medical judgment and is prohibited from relying solely on recommendations from any other source. Additionally, the bill specifies that these changes will take effect on July 1, 2026. The amendments aim to ensure that decisions regarding medical necessity are made with thorough consideration by qualified medical directors, thereby enhancing the accountability and transparency of the claims and prior authorization processes. The current statutes remain unchanged except for these specific insertions.

Statutes affected:
Introduced Version: 20-3103
House Engrossed Version: 20-3103
Senate Engrossed Version: 20-3103, 20-3407
Chaptered Version: 20-3103, 20-3407