This bill establishes a mandatory peer-to-peer review process for insurance carriers during any stage of prior authorization for medical services. It requires that when a provider requests such a review, they must have a direct conversation with a qualified medical director or clinical peer who holds an active license in a relevant specialty and possesses expertise in evaluating the medical necessity of the service. The bill allows for peer-to-peer reviews to be requested both before and after a prior authorization denial, mandating that insurers schedule these reviews within five business days. Insurers are also required to disclose the reviewer's credentials, including their full name, licensure type, and National Provider Identifier (NPI), prior to the conversation.

The legislation modifies existing laws by inserting language that affirms the right of claimants to request a peer-to-peer review at any time, regardless of whether an appeal has been initiated, and it deletes the previous limitation that restricted requests to before a formal grievance was filed. Additionally, the bill introduces penalties for insurers who do not comply with these requirements, classifying such non-compliance as an unfair insurance practice. The act is set to take effect on January 1, 2027. The bill also notes potential impacts on health insurance premiums for counties and municipalities, as well as indeterminate effects on Insurance Premium Tax revenue due to changes in market participation and pricing strategies.

Statutes affected:
Introduced: 420-E:4-b, 420-J:6
HB1554 text: 420-E:4-b, 420-J:6