The "Rhode Island Prior Authorization Reform Act of 2025" amends the existing "Benefit Determination and Utilization Review Act" to streamline healthcare service authorizations by introducing new definitions and provisions. A significant insertion in the bill is the prohibition of prior authorization requirements for any admission, item, service, treatment, or procedure ordered by an in-network primary care provider, with the exception of prescription drugs. This change aims to reduce administrative burdens on both patients and providers, facilitating easier access to necessary healthcare services.

The legislation also updates the responsibilities of the Secretary of the Office of Health and Human Services, ensuring that insurers minimize administrative burdens that may delay medically necessary care. This includes the requirement for insurers to not impose prior authorization for services ordered by in-network primary care providers, while still allowing for prior authorization requirements for prescription drugs.

Additionally, the bill emphasizes the need for improved communication between health plans, providers, and patients regarding prior authorization processes. It mandates that insurers disclose adjudication decisions on claims denied due to temporary code edits and requires the development of a common website for providers to access preauthorization and benefits information.

The act is set to take effect on July 1, 2026, and includes a severability clause to maintain the enforceability of its provisions even if part of the act is deemed unconstitutional or invalid.

Statutes affected:
53: 27-18.9-2, 42-7.2-5, 42-14.5-3