Assembly Bill 432 aims to enhance transparency and regulation of prior authorization requirements for health care services under health insurance plans in Wisconsin. The bill defines prior authorization as the process by which utilization review entities assess the medical necessity of covered health care services before they are provided. Key provisions include requiring that all adverse determinations be made by qualified health care providers, such as physicians or advanced practice registered nurses, under the clinical direction of medical directors. The bill mandates that utilization review entities must render decisions on authorizations or adverse determinations within specified timeframes—72 hours for non-urgent services and 24 hours for urgent services. Additionally, authorizations must remain valid for at least one year and must not be affected by changes in treatment plans for chronic conditions.

The bill also introduces new statutory provisions, specifically creating sections 609.815 and 632.848, which outline the obligations of utilization review entities regarding prior authorizations. It stipulates that if an enrollee switches to a new health insurance plan, the new entity must honor prior authorizations from the previous plan for at least 90 days. Furthermore, the bill prohibits denial of payment for services that have received prior authorization unless there is evidence of misrepresentation by the health care provider or ineligibility of the enrollee at the time of service. The bill includes amendments to existing statutes to incorporate these new requirements, ensuring that health care coverage plans comply with the updated regulations.

Statutes affected:
Bill Text: 40.51(8), 40.51, 40.51(8m), 66.0137(4), 66.0137, 120.13(2)(g), 120.13, 185.983(1)(intro.), 185.983