LEGISLATIVE GENERAL COUNSEL S.B. 275
6 Approved for Filing: C. Williams 6 1st Sub. (Green)
6 03-01-24 6:23 PM 6
Representative Steve Eliason proposes the following substitute bill:
1 MEDICAL PREAUTHORIZATION AMENDMENTS
2 2024 GENERAL SESSION
3 STATE OF UTAH
4 Chief Sponsor: Jen Plumb
5 House Sponsor: Robert M. Spendlove
6
7 LONG TITLE
8 General Description:
9 This bill enacts provisions related to authorization requests.
10 Highlighted Provisions:
11 This bill:
12 < defines terms;
13 < creates deadlines for when a managed care organization must respond to certain
14 authorization requests.
15 Money Appropriated in this Bill:
16 None
17 Other Special Clauses:
18 This bill provides a special effective date.
19 Utah Code Sections Affected:
20 ENACTS: 1st Sub. S.B. 275
21 31A-45-404, Utah Code Annotated 1953
22
23 Be it enacted by the Legislature of the state of Utah:
24 Section 1. Section 31A-45-404 is enacted to read:
25 31A-45-404. Timeliness of decisions for preauthorization.
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1st Sub. (Green) S.B. 275 03-01-24 6:23 PM
26 (1) As used in this section:
27 (a) "Adverse preauthorization determination" means the same as that term is defined in
28 Section 31A-22-650.
29 (b) "Concurrent request" means a request for medical care while the member is in
30 process of receiving requested medical care or services.
31 (c) "Determination" means a determination by a managed care organization, pharmacy
32 benefit manager, or the managed care organization's designee that, based on the member's
33 benefits and plan's policies, a requested service or medication is approved, denied, or reduced.
34 (d) "Nonurgent request" means a request for medical care, medication, or services
35 where a delay of more than 10 days would not jeopardize an individual's health.
36 (e) "Post-acute services" means services and medical care provided to an individual
37 after discharge from a general acute care hospital including:
38 (i) inpatient rehabilitation;
39 (ii) skilled nursing facility services;
40 (iii) home health;
41 (iv) palliative care;
42 (v) hospice; or
43 (vi) medications required for safe transition of care.
44 (f) "Post-service request" means a request for medical care or services after the care or
45 services have been provided.
46 (g) "Preservice request" means a request for medical care or services prior to an
47 individual receiving the requested care or services.
48 (2) For the following requests from a health care provider for medical care or services
49 on behalf of a member of a managed care organization, the managed care organization shall
50 respond within:
51 (a) for a concurrent request, including for post-acute services:
52 (i) 24 hours from the hour the request is transmitted; or
53 (ii) if the managed care organization requests additional information under Subsection
54 (5), 24 hours from the hour the managed care organization receives the additional information;
55 or
56 (b) for a preservice request that is urgent:
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03-01-24 6:23 PM 1st Sub. (Green) S.B. 275
57 (i) 48 hours from the hour the request is transmitted; or
58 (ii) if the managed care organization requests additional information under Subsection
59 (5), 24 hours from the hour the managed care organization received the additional information;
60 (c) for a preservice request that is not urgent, 10 days from the day the request was
61 transmitted; and
62 (d) for a post-service care request, 30 days from the day the request was transmitted.
63 (3) A managed care organization shall complete an appeal from an adverse
64 preauthorization determination in the same amount of time as the time for the applicable
65 request described in Subsection (2).
66 (4) A managed care organization may not deny a post-service request solely because
67 the request for service was initiated after the service was performed.
68 (5) (a) A managed care organization may request additional information for an
69 authorization request described in this section.
70 (b) For a request described in Subsection (2)(a) or (b), the managed care organization
71 shall submit a request for more information no later than 24 hours after the hour the request is
72 transmitted to the managed care organization.
73 (6) If a managed care organization fails to respond to a request described in Subsection
74 (2) within the time specified, or to request information in accordance with Subsection (5)(b)
75 within the time specified, the request is deemed to be approved.
76 (7) This section only applies to requests from a tertiary hospital or a quaternary
77 hospital.
78 (8) This section does not apply to:
79 (a) the Public Employees' Benefit and Insurance Program; or
80 (b) claims filed as part of the Medicaid program.
81 Section 2. Effective date.
82 This bill takes effect on January 1, 2025.
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