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. It 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, and if approved, the insurer must inform the professional of their rights and obligations. The bill also stipulates that insurers can rescind exemptions under certain conditions, including a review of claims submitted by the healthcare professional.

Additionally, the bill mandates that healthcare professionals have the right to request an independent review of any rescission of their prior authorization exemption. The independent review must be completed within thirty days, and the health insurer is responsible for the costs associated with this review. The decision made by the independent review organization is binding, and the bill includes provisions for reinstating exemptions if the review overturns the insurer's decision. The effective date for the provisions of this act is set for January 1, 2026.

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