Existing law authorizes certain health insurers to require prior authorization before an insured may receive coverage for health 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 health and dental care by health insurers, including Medicaid, the Children's Health Insurance Program, insurance for public employees and certain entities designated by health insurers to perform utilization reviews. Specifically, sections 15 and 27 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 15 and 27 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 15 and 27 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 that the care was provided did not require prior authorization for that care. Sections 15 and 28 of this bill revise the period for insurers to take action on a request for prior authorization by requiring an insurer to approve or make an adverse determination on such a request, or request additional, medically relevant information: (1) within 48 hours after receiving the request, for medical or dental care that is not urgent; or (2) within 24 hours after receiving the request, for care that is urgent. Sections 10 and 29 of this bill 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 a person who is responsible for making a determination on the request. Sections 10 and 29 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 11 and 30 of this bill: (1) provide that a request for prior authorization that has been approved by the insurer remains valid for 12 months; and (2) 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 11 and 30 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 12 and 33 of this bill prohibit an insurer from requiring prior authorization for covered emergency services. Sections 12 and 33 also prohibit an insurer from requiring that an insured or provider of health care notify the insurer earlier than the end of the business day following the date of admission or the date on which the emergency services are provided. Finally, sections 12 and 33: (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 3-9 and 23-26 of this bill define certain terms relating to the process of obtaining and processing requests for prior authorization, and sections 2 and 22 of this bill establish the applicability of those definitions. Sections 13 and 32 of this bill provide that if an insurer violates any provision of section 10-12, 15 or 27-31 of this bill with respect to a particular request for prior authorization, that the request is deemed approved. Sections 13 and 32 also clarify that nothing in the provisions of section 10-12, 15 or 27-31 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 14 and 33 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. Section 16 of this bill requires a nonprofit hospital and medical or dental service corporation to comply with sections 2-14. Section 17 of this bill requires the Director of the Department of Health and Human Services to administer the provisions of sections 21-33 of this bill in the same manner as other provisions governing Medicaid. Sections 18, 19 and 35 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 2-15 to the extent applicable. Section 21 provides that a health maintenance organization or another managed care organization that provides services to recipients of Medicaid or the Children's Health Insurance Program is not subject to sections 22-33, but must comply with sections 2-15. Section 34 of this bill requires the policies and procedures for coverage for prescription drugs under Medicaid to comply with sections 22-33.

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