HOUSE BILL NO. 1927 103RD GENERAL ASSEMBLY
INTRODUCED BY REPRESENTATIVE BUSH.
5005H.01I JOSEPH ENGLER, Chief Clerk
AN ACT To repeal section 376.1350, RSMo, and to enact in lieu thereof two new sections relating to prior authorization of inpatient psychiatric hospital services.
Be it enacted by the General Assembly of the state of Missouri, as follows:
Section A. Section 376.1350, RSMo, is repealed and two new sections enacted in lieu 2 thereof, to be known as sections 376.1350 and 376.1368, to read as follows: 376.1350. For purposes of sections 376.1350 to [376.1390] 376.1389, the following 2 terms mean: 3 (1) "Adverse determination", a determination by a health carrier or a utilization 4 review entity that an admission, availability of care, continued stay or other health care 5 service furnished or proposed to be furnished to an enrollee has been reviewed and, based 6 upon the information provided, does not meet the utilization review entity or health carrier's 7 requirements for medical necessity, appropriateness, health care setting, level of care or 8 effectiveness, or are experimental or investigational, and the payment for the requested 9 service is therefore denied, reduced or terminated; 10 (2) "Ambulatory review", utilization review of health care services performed or 11 provided in an outpatient setting; 12 (3) "Case management", a coordinated set of activities conducted for individual 13 patient management of serious, complicated, protracted or other health conditions; 14 (4) "Certification", a determination by a health carrier or a utilization review entity 15 that an admission, availability of care, continued stay or other health care service has been 16 reviewed and, based on the information provided, satisfies the health carrier's requirements 17 for medical necessity, appropriateness, health care setting, level of care and effectiveness, and
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 1927 2
18 that payment will be made for that health care service provided the patient is an enrollee of 19 the health benefit plan at the time the service is provided; 20 (5) "Clinical peer", a physician or other health care professional who holds a 21 nonrestricted license in a state of the United States and in the same or similar specialty as 22 typically manages the medical condition, procedure or treatment under review; 23 (6) "Clinical review criteria", the written policies, written screening procedures, drug 24 formularies or lists of covered drugs, determination rules, decision abstracts, clinical 25 protocols, medical protocols, practice guidelines, and any other criteria or rationale used by 26 the health carrier or utilization review entity to determine the necessity and appropriateness of 27 health care services; 28 (7) "Concurrent review", utilization review conducted during a patient's hospital stay 29 or course of treatment; 30 (8) "Covered benefit" or "benefit", a health care service that an enrollee is entitled 31 under the terms of a health benefit plan; 32 (9) "Director", the director of the department of commerce and insurance; 33 (10) "Discharge planning", the formal process for determining, prior to discharge 34 from a facility, the coordination and management of the care that a patient receives following 35 discharge from a facility; 36 (11) "Drug", any substance prescribed by a licensed health care provider acting within 37 the scope of the provider's license and that is intended for use in the diagnosis, mitigation, 38 treatment or prevention of disease. The term includes only those substances that are approved 39 by the FDA for at least one indication; 40 (12) "Emergency medical condition", the sudden and, at the time, unexpected onset of 41 a health condition that manifests itself by symptoms of sufficient severity, regardless of the 42 final diagnosis that is given, that would lead a prudent lay person, possessing an average 43 knowledge of medicine and health, to believe that immediate medical care is required, which 44 may include, but shall not be limited to: 45 (a) Placing the person's health in significant jeopardy; 46 (b) Serious impairment to a bodily function; 47 (c) Serious dysfunction of any bodily organ or part; 48 (d) Inadequately controlled pain; or 49 (e) With respect to a pregnant woman who is having contractions: 50 a. That there is inadequate time to effect a safe transfer to another hospital before 51 delivery; or 52 b. That transfer to another hospital may pose a threat to the health or safety of the 53 woman or unborn child; HB 1927 3
54 (13) "Emergency service", a health care item or service furnished or required to 55 evaluate and treat an emergency medical condition, which may include, but shall not be 56 limited to, health care services that are provided in a licensed hospital's emergency facility by 57 an appropriate provider; 58 (14) "Enrollee", a policyholder, subscriber, covered person or other individual 59 participating in a health benefit plan; 60 (15) "FDA", the federal Food and Drug Administration; 61 (16) "Facility", an institution providing health care services or a health care setting, 62 including but not limited to hospitals and other licensed inpatient centers, ambulatory surgical 63 or treatment centers, skilled nursing centers, residential treatment centers, diagnostic, 64 laboratory and imaging centers, and rehabilitation and other therapeutic health settings; 65 (17) "Grievance", a written complaint submitted by or on behalf of an enrollee 66 regarding the: 67 (a) Availability, delivery or quality of health care services, including a complaint 68 regarding an adverse determination made pursuant to utilization review; 69 (b) Claims payment, handling or reimbursement for health care services; or 70 (c) Matters pertaining to the contractual relationship between an enrollee and a health 71 carrier; 72 (18) "Health benefit plan", a policy, contract, certificate or agreement entered into, 73 offered or issued by a health carrier to provide, deliver, arrange for, pay for, or reimburse any 74 of the costs of health care services; except that, health benefit plan shall not include any 75 coverage pursuant to liability insurance policy, workers' compensation insurance policy, or 76 medical payments insurance issued as a supplement to a liability policy; 77 (19) "Health care professional", a physician or other health care practitioner licensed, 78 accredited or certified by the state of Missouri to perform specified health services consistent 79 with state law; 80 (20) "Health care provider" or "provider", a health care professional or a facility; 81 (21) "Health care service", a service for the diagnosis, prevention, treatment, cure or 82 relief of a health condition, illness, injury or disease, including but not limited to the provision 83 of drugs or durable medical equipment; 84 (22) "Health carrier", an entity subject to the insurance laws and regulations of this 85 state that contracts or offers to contract to provide, deliver, arrange for, pay for or reimburse 86 any of the costs of health care services, including a sickness and accident insurance company, 87 a health maintenance organization, a nonprofit hospital and health service corporation, or any 88 other entity providing a plan of health insurance, health benefits or health services; except 89 that such plan shall not include any coverage pursuant to a liability insurance policy, workers' HB 1927 4
90 compensation insurance policy, or medical payments insurance issued as a supplement to a 91 liability policy; 92 (23) "Health indemnity plan", a health benefit plan that is not a managed care plan; 93 (24) "Inpatient psychiatric hospital services", inpatient hospital services 94 furnished to an inpatient of a mental health facility, as defined in section 632.005, for 95 the treatment of a mental disorder or mental illness, as such terms are defined in section 96 630.005; 97 (25) "Managed care plan", a health benefit plan that either requires an enrollee to use, 98 or creates incentives, including financial incentives, for an enrollee to use, health care 99 providers managed, owned, under contract with or employed by the health carrier; 100 [(25)] (26) "Participating provider", a provider who, under a contract with the health 101 carrier or with its contractor or subcontractor, has agreed to provide health care services to 102 enrollees with an expectation of receiving payment, other than coinsurance, co-payments or 103 deductibles, directly or indirectly from the health carrier; 104 [(26)] (27) "Peer-reviewed medical literature", a published scientific study in a 105 journal or other publication in which original manuscripts have been published only after 106 having been critically reviewed for scientific accuracy, validity and reliability by unbiased 107 independent experts, and that has been determined by the International Committee of Medical 108 Journal Editors to have met the uniform requirements for manuscripts submitted to 109 biomedical journals or is published in a journal specified by the United States Department of 110 Health and Human Services pursuant to Section 1861(t)(2)(B) of the Social Security Act (42 111 U.S.C. Section 1395x), as amended, as acceptable peer-reviewed medical literature. Peer- 112 reviewed medical literature shall not include publications or supplements to publications that 113 are sponsored to a significant extent by a pharmaceutical manufacturing company or health 114 carrier; 115 [(27)] (28) "Person", an individual, a corporation, a partnership, an association, a joint 116 venture, a joint stock company, a trust, an unincorporated organization, any similar entity or 117 any combination of the foregoing; 118 [(28)] (29) "Prior authorization", a certification made pursuant to a prior authorization 119 review, or notice as required by a health carrier or utilization review entity prior to the 120 provision of health care services; 121 [(29)] (30) "Prior authorization review", utilization review conducted prior to an 122 admission or a course of treatment, including but not limited to pre-admission review, 123 pretreatment review, utilization review, and case management; 124 [(30)] (31) "Retrospective review", utilization review of medical necessity that is 125 conducted after services have been provided to a patient, but does not include the review of a HB 1927 5
126 claim that is limited to an evaluation of reimbursement levels, veracity of documentation, 127 accuracy of coding or adjudication for payment; 128 [(31)] (32) "Second opinion", an opportunity or requirement to obtain a clinical 129 evaluation by a provider other than the one originally making a recommendation for a 130 proposed health service to assess the clinical necessity and appropriateness of the initial 131 proposed health service; 132 [(32)] (33) "Stabilize", with respect to an emergency medical condition, that no 133 material deterioration of the condition is likely to result or occur before an individual may be 134 transferred; 135 [(33)] (34) "Standard reference compendia": 136 (a) The American Hospital Formulary Service-Drug Information; or 137 (b) The United States Pharmacopoeia-Drug Information; 138 [(34)] (35) "Utilization review", a set of formal techniques designed to monitor the 139 use of, or evaluate the clinical necessity, appropriateness, efficacy, or efficiency of, health 140 care services, procedures, or settings. Techniques may include ambulatory review, prior 141 authorization review, second opinion, certification, concurrent review, case management, 142 discharge planning or retrospective review. Utilization review shall not include elective 143 requests for clarification of coverage; 144 [(35)] (36) "Utilization review entity", a utilization review agent as defined in section 145 374.500, or an individual or entity that performs prior authorization reviews for a health 146 carrier or health care provider. A health carrier or health care provider is a utilization review 147 entity if it performs prior authorization review. 376.1368. A health carrier shall not require prior authorization of inpatient 2 psychiatric hospital services. ✔
Statutes affected: