The Ensuring Transparency in Prior Authorization Act aims to improve the transparency and efficiency of the prior authorization process in health insurance. It introduces definitions for key terms such as "adverse determination," "chronic condition," and "prior authorization," and requires utilization review entities to make their current prior authorization requirements and clinical criteria accessible on their websites. The bill mandates that any new or amended prior authorization requirements be communicated to affected health care providers and enrollees at least sixty days prior to implementation. Additionally, it stipulates that all adverse determinations must be made by a qualified physician and outlines notification processes for health care providers, including opportunities for discussion regarding treatment plans.

The legislation also sets specific timeframes for prior authorization decisions, requiring urgent requests to be addressed within twelve hours and non-urgent requests within three days. It introduces a uniform prior authorization request form to be used by all health care providers starting January 1, 2026, and establishes that necessary information for prior authorization includes results from clinical evaluations. The bill ensures automatic authorization of health care services if utilization review entities fail to meet deadlines and specifies that certain services, such as emergency care and preventive services rated A or B by the U.S. Preventive Services Task Force, cannot require prior authorization. Furthermore, it emphasizes the role of artificial intelligence in decision-making, prohibits compensation based on denial volumes, and mandates annual reporting of prior authorization practices by health carriers. The provisions are set to take effect on January 1, 2026.