The bill amends the General Laws to impose restrictions on prior authorization requirements for rehabilitative and habilitative services in health insurance plans. It specifically prohibits these plans from requiring prior authorization for the first twelve visits of each new episode of care, which includes services such as physical therapy and occupational therapy. After these initial visits, prior authorization cannot be required more frequently than every six visits or every thirty days, whichever time period is longer. The bill defines a "new episode of care" as treatment for a new or recurring condition for which an insured has not been treated by the provider within the previous ninety days.

Additionally, the bill prohibits health insurance plans from requiring prior authorization for physical medicine or rehabilitation services provided to patients with chronic pain for the first ninety days following diagnosis. After this period, prior authorization cannot be required more frequently than every six visits or every thirty days, whichever is longer. "Chronic pain" is defined as pain that persists or recurs for more than three months.

The bill mandates that health insurance plans respond to prior authorization requests for services or visits in an ongoing plan of care within twenty-four hours. If additional information is required to render a decision, the health insurance plan must notify the patient and provider within twenty-four hours of the initial request, specifying the information needed. A prior authorization request is deemed approved if the health insurance plan fails to respond in a timely manner or informs a provider that prior authorization is not required.

Furthermore, the bill requires health insurance plans to provide a procedure for obtaining retroactive authorization for medically necessary covered benefits. Coverage cannot be denied for medically necessary services due to failure to obtain prior authorization if a medical necessity determination can be made after the services have been provided.

The bill also states that a health insurance plan's failure to approve a prior authorization for all rehabilitative or habilitative services or visits in a plan of care is subject to the same appeal rights as a denial under the health insurance commissioner's rules regarding health plan accountability and the provider's network agreement with the carrier. Lastly, nothing in this section prohibits a health insurance plan from performing a retrospective medical necessity review.

The act is set to take effect on January 1.