Existing law authorizes certain health insurers to require prior authorization before an insured may receive coverage for medical and dental care in certain circumstances. If an insurer requires prior authorization, existing law requires the insurer to: (1) file its procedure for obtaining prior authorization with the Commissioner of Insurance for approval; and (2) respond to a request for prior authorization within 20 days after receiving the request. (NRS 687B.225) This bill establishes additional requirements relating to the use of prior authorization for medical and dental care by health insurers, including Medicaid, the Children's Health Insurance Program and insurance for public employees. Specifically, sections 27 and 44 of this bill require that a procedure for obtaining prior authorization includes: (1) a list of the specific goods and services for which the insurer requires prior authorization; and (2) the clinical review criteria used by the insurer to evaluate requests for prior authorization. Sections 27 and 44 also require an insurer to publish its procedure for obtaining prior authorization on its Internet website and update that website as necessary to account for any changes in the procedure. Sections 27 and 44 prohibit an insurer from denying a claim for payment for medical or dental care because of the failure to obtain prior authorization if the insurer's procedures for obtaining prior authorization in effect on the date on which the care was provided did not require prior authorization for that care. Sections 27 and 45 of this bill revise the period for insurers to take action on a request for prior authorization by requiring an insurer to approve or deny such a request, or request additional, medically relevant information within: (1) 48 hours after receiving the request, for medical or dental care that is not urgent; or (2) 24 hours after receiving the request, for care that is urgent. Sections 17 and 46 of this bill require any adverse determination on a request for prior authorization to be made by a physician or, for a request relating to dental care, a dentist, who is licensed in this State and possesses certain other qualifications. Sections 17 and 46 require an insurer, in certain circumstances, to allow the provider of health care who requested the prior authorization to discuss the issues involved in the request with the physician or dentist who is responsible for making a determination on the request. Sections 17 and 46 require an insurer, upon making an adverse determination on a request for prior authorization, to transmit certain information to the insured to whom the request pertains, including information relating to the right of the insured to appeal the adverse determination. Sections 17 and 46 further require: (1) an insurer to establish a process for appeals that provides for the timely resolution of appeals submitted by insureds; and (2) a decision upholding an adverse determination on an appeal submitted by an insured to be made by a physician or dentist who has qualifications beyond those required of a physician or dentist who evaluates initial requests for prior authorization. Sections 18 and 47 of this bill provide that a request for prior authorization that has been approved by the insurer remains valid for: (1) 12 months; or (2) treatment related to a chronic condition, until the standard of treatment for that condition changes. Sections 18 and 47 prohibit an insurer from requiring an insured to obtain additional prior authorization for a course of treatment or regimen of medication previously approved by the insurer. Section 18 requires an insurer to honor an approval of a request for prior authorization so long as the approval remains valid, even if the insured obtains coverage under a different policy issued by the insurer. Sections 18 and 47 also prohibit an insurer from denying or imposing additional limits on a request for prior authorization that the insurer has previously approved if the care at issue in the request is provided within 45 business days after the date on which the insurer receives the request and certain other requirements are met. Sections 18 and 47 require an insurer that approves a request for prior authorization to pay the provider of health care the full applicable rate for the relevant care, except in certain circumstances. Finally, Sections 18 and 47 require an insurer, for the first 90 days of the coverage period for a new insured, to honor a request for prior authorization that has been approved by the previous insurer of the new insured, under certain circumstances. Sections 19, 48 and 55 of this bill prohibit an insurer from requiring an insured to obtain prior authorization for certain medical care, including certain preventive care services. Sections 20 and 49 of this bill prohibit an insurer from requiring prior authorization for covered emergency services. Sections 20 and 49 prohibit an insurer from requiring that an insured or provider of health care notify the insurer earlier than the end of the business day immediately following the date of admission or the date on which the emergency services are provided. Sections 20 and 49 also require an insurer to respond to a request for prior authorization for certain follow-up care relating to the emergency care received by an insured within 60 minutes after receiving the request. Finally, Sections 20 and 49: (1) prohibit an insurer from denying coverage for covered medically necessary emergency services; and (2) establish a presumption of medical necessity under certain conditions. Sections 24 and 55 of this bill require insurers to receive and respond to requests for prior authorization for prescription drugs through a secure transmission that complies with a standard established by the National Council for Prescription Drug Programs for the electronic transmission of pharmaceutical records. Sections 21 and 50 of this bill require insurers to exempt providers of health care from the requirement to obtain prior authorization for specific goods and services if the insurer has granted requests for prior authorization for those goods or services submitted by the provider at a rate of 80 percent or more during the previous year. Sections 21 and 50 require insurers to annually conduct reviews of each provider of health care in the network of the insurer or who has submitted a request for prior authorization to Medicaid in the immediately preceding 12 months, as applicable, to determine whether each such provider qualifies for an exemption. If the provider qualifies for an exemption, sections 21 and 50 require the insurer to automatically grant the exemption for the applicable goods and services, without requiring the provider to affirmatively request an exemption. Sections 22 and 51 of this bill prescribe the requirements and procedure for an insurer to revoke an exemption granted to a provider of health care. Sections 22 and 51 also require an insurer to establish a procedure by which a provider of health care may appeal a revocation of an exemption. Sections 3-16 and 35-43 of this bill define certain terms relating to the process of obtaining and processing requests for prior authorization, and sections 2 and 34 of this bill establish the applicability of those definitions. Sections 23 and 52 of this bill provide that if an insurer violates any provision of section 17-20, 27 or 44-49 with respect to a particular request for prior authorization, that the request is deemed approved. Sections 23 and 52 also clarify that nothing in any provision of section 17-22, 27 or 44-51 require an insurer to provide coverage: (1) for care that the insurer does not cover, regardless of the medical necessity of the care; or (2) to persons to whom the insured is not obligated to provide coverage. Sections 25 and 53 of this bill require an insurer to annually publish on its Internet website certain information relating to requests for prior authorization that have been processed by the insurer during the immediately preceding year. Sections 26 and 54 of this bill additionally require an insurer to publish an annual report of certain information relating to requests for prior authorization processed by the insurer during the immediately preceding year. Section 28 of this bill requires a nonprofit hospital and medical or dental service corporation to comply with sections 2-26. Section 29 of this bill requires the Director of the Department of Health and Human Services to administer the provisions of sections 33-54 of this bill in the same manner as other provisions governing Medicaid. Sections 30, 31 and 56 of this bill require plans of self-insurance for employees of local governments, the Public Employees' Benefits Program and plans of self-insurance for private employers, respectively, to comply with the requirements of sections 2-26 to the extent applicable. Section 33 provides that a managed care organization that provides services to recipients of Medicaid or the Children's Health Insurance Program is not subject to sections 34-54, but must comply with sections 2-26. Section 55 requires the policies and procedures for coverage for prescription drugs under Medicaid to comply with sections 34-54.

Statutes affected:
As Introduced: 687B.225, 695B.320, 232.320, 287.010, 287.04335, 422.403, 608.1555
BDR: 687B.225, 695B.320, 232.320, 287.010, 287.04335, 422.403, 608.1555