The bill seeks to improve the health insurance prior authorization process by implementing several key provisions. It requires all licensed carriers providing medical or prescription drug benefits to maintain a publicly accessible, searchable list of items, services, and medications that require prior authorization. Additionally, carriers must report annual data on prior authorization requests, including approval and denial rates, to the division of insurance. The bill mandates that if a carrier intends to implement or amend prior authorization requirements, they must update their website and notify affected individuals. It also prohibits retrospective denial of authorization for services already approved unless based on fraudulent information.

Furthermore, the bill introduces guidelines for utilization review criteria, emphasizing evidence-based practices developed with physician input. It mandates that prior authorization requests be processed through an automated application programming interface to ensure compliance with federal standards. The use of artificial intelligence in the utilization review process is regulated, ensuring that such tools do not solely determine medical necessity and that decisions are made by licensed healthcare providers. The legislation also establishes a task force to study the impact of prior authorization on healthcare costs and access, and it amends existing laws to align prior authorization forms with national standards. The bill outlines a timeline for implementation, with certain provisions taking effect on January 1, 2026, and others on April 1, 2027, ultimately aiming to streamline processes and enhance patient access to care.

Statutes affected:
Bill Text: 175-24B