This bill enacts a new section of the Prior Authorization Act, requiring health insurers to establish procedures for granting exemptions from their prior authorization process for healthcare professionals who meet specific criteria. The bill defines terms such as "abuse" and "fraud" and outlines the process for healthcare professionals to apply for exemptions after an evaluation period. If a healthcare professional's prior authorization exemption request is denied, the insurer must provide a written explanation. Additionally, the bill stipulates that insurers can rescind exemptions based on a review of claims, with specific notice requirements and the right for healthcare professionals to request an independent review of the rescission.

The bill also includes provisions for the independent review process, ensuring that it is conducted by a licensed medical professional in the same specialty as the healthcare professional requesting the review. The health insurer is responsible for the costs associated with the independent review and must comply with the review organization's decision. The effective date for the provisions of this act is set for January 1, 2026.

Statutes affected:
introduced version: 59A-22B-1