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 exemption request is denied, the insurer must provide a written explanation, and if approved, the insurer must inform the professional of their rights and obligations. The bill also stipulates that insurers can rescind exemptions based on a review of claims, with specific notice requirements and the right for professionals to request an independent review of such determinations.

Additionally, the bill includes provisions for independent reviews conducted by licensed medical professionals, ensuring that the health insurer bears the costs associated with these reviews. It establishes that the decisions made by independent review organizations are binding and outlines the conditions under which prior authorization exemptions can be reinstated or denied. The effective date for the provisions of this act is set for January 1, 2026.

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