The Ensuring Transparency in Prior Authorization Act introduces comprehensive regulations to improve the prior authorization processes in health insurance and Medicaid, particularly for biomarker testing. Key provisions include the requirement for utilization review agents to make prior authorization criteria publicly accessible on their websites and to notify healthcare providers of any changes at least sixty days in advance. The bill mandates that adverse determinations be made by qualified physicians and establishes strict timeframes for decision-making, especially for urgent cases starting January 1, 2028. It also prohibits prior authorization for certain emergency services and preventive care, ensures that approved authorizations remain valid for sixty days post-care, and introduces a uniform request form to streamline the process.

Additionally, the bill emphasizes the importance of biomarker testing by mandating its coverage under specific conditions and requiring that it demonstrates clinical utility. It ensures that prior authorizations are honored for the first sixty days of a new health benefit plan and prohibits the use of artificial intelligence as the sole basis for service denial. The legislation aims to enhance transparency, limit disruptions in care, and promote a fair review process by preventing health carriers from being incentivized based on denial volumes. Overall, the bill seeks to improve access to necessary healthcare services and the quality of care provided to enrollees.