The 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 key terms such as "abuse," "fraud," and "outpatient health care services," and outlines the process for healthcare professionals to apply for exemptions. To qualify, a healthcare professional must have at least 90% of their prior authorization requests approved during the evaluation period. Insurers are mandated to respond to exemption requests within ten business days and provide explanations for any denials.

Additionally, the bill stipulates that health insurers can rescind exemptions only after determining that less than 90% of claims submitted by the healthcare professional meet medical necessity criteria, and they must provide written notice before rescission. It also allows for independent reviews of rescission decisions, ensuring that healthcare professionals can contest these determinations without first undergoing an internal appeal process. The bill emphasizes the importance of transparency and accountability in the prior authorization process, aiming to streamline access to necessary healthcare services while maintaining oversight to prevent fraud and abuse.

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