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 utilization review entity demands prior authorization, the provider must have the opportunity to discuss the authorization request directly with a medical director or designated clinical peer. The bill defines a "clinical peer" with specific criteria, including active licensure and practice in a similar specialty. Additionally, it allows for peer-to-peer reviews to be requested after a prior authorization denial, irrespective of whether an appeal has been initiated, and mandates that these reviews be scheduled within set timeframes.

The legislation also introduces new disclosure requirements for insurers, compelling them to provide the reviewing provider with the reviewer's full name, licensure type, issuing state, and National Provider Identifier (NPI) prior to the peer-to-peer conversation. Non-compliance with these requirements is deemed an unfair insurance practice, subject to administrative penalties. The bill amends existing laws by removing the limitation that peer-to-peer reviews can only be requested before a formal grievance request. While the bill addresses potential impacts on medical loss ratio requirements and acknowledges that counties and municipalities may see changes in health insurance premiums, it does not provide specific details on the insertions and deletions made to current law. The act is set to take effect on January 1, 2027.

Statutes affected:
Introduced: 420-E:4-b, 420-J:6
As Amended by the House: 420-E:4-b, 420-J:6
HB1554 text: 420-E:4-b, 420-J:6