Present law generally requires that a health care provider notify a patient of communication between the provider and a health insurance entity or healthcare facility concerning additional information needed to process a prior authorization request for the patient within five business days after the communication has occurred. The notification must include a brief summary of the communication or a copy of the communication. This bill limits such requirement to communications between the provider and the patient's health insurance entity, changes the period within which the patient must be notified to seven calendar days, and removes the requirement for a summary of the communication. Under present law, if a utilization review agent requires additional information from an enrollee, a provider, or healthcare facility to make a determination on a request for prior authorization, then, no later than five business days after receipt of the request, the agent is required to notify: (1) The enrollee in writing, or through email or respective electronic portals, of the additional information needed to make the determination; and (2) The provider or healthcare facility through email or respective electronic portals of the additional information needed to make the determination This bill changes the notice requirement for utilization review agents to instead require that, if a utilization review organization makes a request of the healthcare provider that additional information is needed to process a prior authorization and the healthcare provider does not submit the additional information within a seven-calendar-day timeframe, then the utilization review organization must notify the enrollee that further information has been requested from the provider. The notification must include a copy of the communication. ON MARCH 13, 2025, THE SENATE ADOPTED AMENDMENT #1 AND PASSED SENATE BILL 1063, AS AMENDED. AMENDMENT #1 rewrites the bill to, instead, remove the following provisions in present law:  A provider must generally notify a patient of communication between the provider and a health insurance entity or healthcare facility concerning additional information needed to process a prior authorization request for the patient within five business days after the communication has occurred. The notification must include a brief summary of the communication or a copy of the communication. However, if the patient is a minor, then the provider must notify the policyholder whose health insurance coverage covers the minor.  Such provider must so notify the patient via electronic means, such as by email or through an online patient portal offered by the provider, unless the patient requests, in writing, an alternative notification method.  If a utilization review agent requires additional information from an enrollee, a provider, or healthcare facility to make a determination on a request for prior authorization, then, no later than five business days after receipt of the request, the agent must notify (i) the enrollee in writing, or through email or respective electronic portals, of the additional information needed to make the determination and (ii) the provider or healthcare facility through email or respective electronic portals of the additional information needed to make the determination.

Statutes affected:
Introduced: 63-1-171, 56-6-705(a), 56-6-705