The Ensuring Transparency in Prior Authorization Act introduces comprehensive regulations aimed at improving the prior authorization processes in health insurance and Medicaid, particularly for biomarker testing. Key definitions are established, including "adverse determination," "clinical peer," and "prior authorization." The bill mandates that utilization review agents must make their prior authorization requirements and clinical review criteria publicly accessible online. Additionally, any new or amended prior authorization requirements must be communicated to healthcare providers at least sixty days in advance. The legislation sets strict timelines for decision-making, requiring urgent requests to be addressed within 48 to 72 hours and non-urgent requests within seven days, while also prohibiting prior authorization for emergency services and certain preventive services.

Moreover, 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 requires transparency in its application during the review process. The legislation also mandates coverage for biomarker testing by health insurance policies and the medical assistance program by January 1, 2028, contingent on demonstrating clinical utility. Overall, the bill aims to enhance patient access to necessary medical services while promoting fair practices in the utilization review process.