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 insurance for public employees as well as specific requirements relating to prior authorization under Medicaid and the Children's Health Insurance Program (CHIP). Specifically, sections 19 and 34 of this bill require that a procedure for obtaining prior authorization includes: (1) a list of the items 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 19 and 34 also require an insurer to publish its procedure for obtaining prior authorization on its Internet website. Sections 19 and 34 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. Section 12.5 of this bill requires insurers, other than those covering recipients of Medicaid and CHIP, which employ or utilize an artificial intelligence system or automated decision tool to process requests for prior authorization to transmit a notice to each insured that: (1) discloses the insurer's use of the system or tool to process requests for prior authorization; and (2) describes certain aspects of the system or tool. Section 12.5 also prohibits an insurer from using an artificial intelligence system or automated decision tool to make an adverse determination on a request for prior authorization, or to terminate, reduce or modify a previously approved request for prior authorization, unless that action is independently reviewed by a physician or dentist, as applicable, who possesses certain qualifications. Section 19 requires an insurer, other than an insurer covering recipients of Medicaid or CHIP, to approve or make an adverse determination on a request for prior authorization, or request additional, medically relevant information within: (1) 7 days after receiving the request, for medical or dental care that is not urgent; or (2) 48 hours after receiving the request, for care that is urgent. Section 35 of this bill requires entities providing coverage under Medicaid or CHIP, including Medicaid managed care organizations, to approve, make an adverse determination on or request additional, medically relevant information for any request for prior authorization, except for requests for prescription drugs and certain other services, within 7 days after receiving the request. Sections 13 and 36 of this bill require any adverse determination on a request for prior authorization to be made by certain authorized providers of health care. Section 13 requires an insurer, other than those covering recipients of Medicaid or CHIP, to, in certain circumstances, allow the provider of health care who requested the prior authorization, or certain colleagues of the provider, to discuss the issues involved in the request with the physician or dentist who is responsible for making a determination on the request. Sections 13 and 36 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. Section 13 requires: (1) an insurer, other than those covering recipients of Medicaid or CHIP, 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. Section 36 establishes certain other requirements for appeals of adverse determinations pertaining to recipients of Medicaid and CHIP. Section 14 of this bill: (1) provides that a request for prior authorization that has been approved by an insurer, other than an insurer covering recipients of Medicaid or CHIP, remains valid for 12 months, if the approval is for a continuous course of care relating to a chronic or long-term condition, or 6 months for other medical or dental care; and (2) requires such 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. Section 37 of this bill provides that a request for prior authorization approved for recipients of Medicaid and CHIP remains valid for 12 months after approval, unless federal law provides for a different amount of time. Sections 15 and 38 of this bill prohibit an insurer from requiring prior authorization for covered emergency services. Sections 15 and 38 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. Additionally, section 38: (1) prohibits an insurer covering recipients of Medicaid and CHIP from denying coverage for covered medically necessary emergency services; and (2) establishes a presumption of such medical necessity under certain conditions. Sections 3-12 and 27-32 of this bill define certain terms relating to the process of obtaining and processing requests for prior authorization, and sections 2 and 26 of this bill establish the applicability of those definitions. Section 16 of this bill provide that if an insurer, other than an insurer covering recipients of Medicaid or CHIP, violates any provision of section 12.5-15 or 19 with respect to a particular request for prior authorization, that the request is deemed approved. Sections 16 and 39 of this bill clarify that nothing in any provision of section 12.5-15, 19 or 34-38 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. Section 17 of this bill requires an insurer, other than an insurer covering recipients of Medicaid or CHIP, to annually publish on its Internet website and submit to the Commissioner of Insurance certain information relating to requests for prior authorization that have been processed by the insurer during the immediately preceding year. Section 17 additionally requires the Commissioner to biennially transmit to the Legislature the data collected from insurers for the biennium and a report summarizing the data. Sections 40 and 41 of this bill impose similar reporting requirements on entities providing coverage for recipients and CHIP relating to requests for prior authorization received by those entities. Section 20 of this bill requires a nonprofit hospital and medical or dental service corporation to comply with sections 2-17. Section 21 of this bill requires the Director of the Department of Health and Human Services to administer the provisions of sections 26-41 of this bill in the same manner as other provisions governing Medicaid. Sections 22, 23 and 44 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 2-19 of this bill to the extent applicable. Sections 12.2 and 34 of this bill provide that a managed care organization that provides services to recipients of Medicaid or the Children's Health Insurance Program is subject to the requirements of sections 26-41, and is not required to comply with sections 2-19. Section 42 of this bill requires the policies and procedures for coverage for prescription drugs under Medicaid to comply with sections 26-41. Section 47.5 of this bill repeals provisions establishing certain requirements relating to prior authorization for dental care which sections 2-19 make redundant.

Statutes affected:
As Introduced: 687B.225, 695B.320, 232.320, 287.010, 287.04335, 422.403, 439B.736, 608.1555
Reprint 1: 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, 439B.736, 608.1555