The Ensuring Transparency in Prior Authorization Act introduces comprehensive regulations aimed at improving the prior authorization processes in health insurance and Medicaid, with a particular emphasis on biomarker testing. The bill defines key terms such as "adverse determination," "clinical peer," and "prior authorization," and requires utilization review agents to make their prior authorization criteria publicly accessible on their websites. It mandates that any changes to prior authorization requirements be communicated to healthcare providers at least sixty days in advance. The legislation also establishes strict timelines for decision-making, requiring urgent requests to be processed within 48 to 72 hours and non-urgent requests within seven days, while prohibiting prior authorization for emergency and certain preventive services.

Additionally, the bill ensures that prior authorizations remain valid for at least one year and outlines specific conditions for inpatient care, including timely responses for continuation requests. It prohibits the use of artificial intelligence as the sole basis for denying or modifying healthcare services and mandates transparency regarding its application in the review process. The legislation also guarantees coverage for biomarker testing by January 1, 2028, defining the criteria for such coverage and ensuring that the medical assistance program provides these tests at the same scope and frequency as other services. The provisions of the bill are set to become operative on January 1, 2026, with other sections taking effect on their designated dates.