HOUSE BILL NO. 1675 103RD GENERAL ASSEMBLY
INTRODUCED BY REPRESENTATIVE SEITZ.
3871H.01I JOSEPH ENGLER, Chief Clerk
AN ACT To amend chapter 376, RSMo, by adding thereto five new sections relating to prior authorization of health care services.
Be it enacted by the General Assembly of the state of Missouri, as follows:
Section A. Chapter 376, RSMo, is amended by adding thereto five new sections, to be 2 known as sections 376.2100, 376.2102, 376.2104, 376.2106, and 376.2108, to read as 3 follows: 376.2100. 1. Except as otherwise provided in subsection 1 of section 376.2108, as 2 used in sections 376.2100 to 376.2108, terms shall have the same meanings as are 3 ascribed to them under section 376.1350. 4 2. As used in sections 376.2100 to 376.2108, the term "evaluation period" shall 5 mean the first six months of the calendar year or the last six months of the calendar 6 year. 376.2102. 1. A health carrier or utilization review entity shall not require a 2 health care provider to obtain prior authorization for a health care service unless the 3 health carrier or utilization review entity makes a determination that in the most recent 4 evaluation period the health carrier or utilization review entity has approved or would 5 have approved less than ninety percent of the prior authorization requests submitted by 6 that provider for that health care service. 7 2. A health carrier or utilization review entity shall not require a health care 8 provider to obtain prior authorization for any health care services unless the health 9 carrier or utilization review entity makes a determination that in the most recent 10 evaluation period the health carrier or utilization review entity has approved or would
EXPLANATION — Matter enclosed in bold-faced brackets [thus] in the above bill is not enacted and is intended to be omitted from the law. Matter in bold-face type in the above bill is proposed language. HB 1675 2
11 have approved less than ninety percent of all prior authorization requests submitted by 12 that provider for health care services. 13 3. In making a determination under this section, the health carrier or utilization 14 review entity shall not count any prior authorization requests denied by a health carrier 15 or utilization review entity and being appealed by the health care provider but shall 16 count as approved any prior authorization request that was denied by a health carrier 17 or utilization review entity but that was subsequently authorized. 376.2104. 1. The health carrier or utilization review entity shall notify the health 2 care provider no later than twenty-five days after the conclusion of the relevant 3 evaluation period of any determination made under section 376.2102. The notification 4 shall include the statistics, data, and any supporting documentation for making the 5 determination for the relevant evaluation period. 6 2. The health carrier or utilization review entity shall establish a process for 7 health care providers to appeal any determinations made under section 376.2102. 8 3. The health carrier or utilization review entity shall maintain an online portal 9 to allow health care providers to access all prior authorization decisions, including 10 determinations made under section 376.2102. For health care providers subject to prior 11 authorizations, the portal shall include the status of each prior authorization request, all 12 notifications to the health care provider, the dates the health care provider received such 13 notifications, and any other information relevant to the determination. 376.2106. No health carrier or utilization review entity shall deny or reduce 2 payment to a health care provider for a health care service for which the provider has a 3 prior authorization unless the provider: 4 (1) Knowingly and materially misrepresented the health care service in a request 5 for payment submitted to the health carrier or utilization review entity with the specific 6 intent to deceive and obtain an unlawful payment from the carrier or entity; or 7 (2) Failed to substantially perform the health care service. 376.2108. 1. The provisions of sections 376.2100 to 376.2108 shall not apply to 2 MO HealthNet, except that a Medicaid managed care organization as defined in section 3 208.431 shall be considered a health carrier for purposes of sections 376.2100 to 4 376.2108. 5 2. The provisions of sections 376.2100 to 376.2108 shall not apply to health care 6 providers who have not participated in a health benefit plan offered by the health 7 carrier for at least one full evaluation period. 8 3. Nothing in sections 376.2100 to 376.2108 shall be construed to: 9 (1) Authorize a health care provider to provide a health care service outside the 10 scope of his or her applicable license; or HB 1675 3
11 (2) Require a health carrier or utilization review entity to pay for a health care 12 service described in subdivision (1) of this subsection. ✔
Statutes affected: