Committee Bill No. 6, introduced in the January Session of 2023 and effective October 1, 2023, proposes amendments to the utilization review process for health care services and insurance coverage for newborns. The bill outlines the conditions under which health carriers must grant exemptions from prospective or concurrent review to participating providers, based on a high approval rate of such requests in the previous six-month period. It also details the process for independent review of adverse determinations made by health carriers regarding these exemptions, including the binding nature of the independent review organization's decision, except where other legal remedies exist. The bill mandates that health carriers provide written notice of exemption qualifications and payment requirements, and it requires the Insurance Commissioner to adopt regulations for implementing fees associated with independent reviews.

The bill also introduces changes to the timeframes for health carriers to respond to review requests, shortening the period for nonurgent care determinations to seventy-two hours and for urgent care determinations to twenty-four hours. It requires health carriers to process review requests continuously and to provide detailed written notices for adverse determinations, including the right to assistance and appeal. Furthermore, the bill extends the notification and payment period for newborn coverage from 61 to 121 days post-birth or hospital discharge and prohibits the requirement of mail-order pharmacies for prescription benefits. It limits step therapy to 60 days and expands protections for prescribed drugs, preventing health carriers from requiring review of recurring services or drugs after initial certification, with some exceptions.

Statutes affected:
Committee Bill:
INS Joint Favorable:
File No. 337:
APP Joint Favorable: