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 physician assistants, under the clinical direction of a medical director. 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 for the duration of treatment for chronic conditions.

The bill also introduces new statutory sections, specifically 609.815 and 632.848, which outline the obligations of utilization review entities regarding prior authorization. It stipulates that if an enrollee switches to a new health insurance plan, the new entity must accept 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 the enrollee was ineligible for coverage at the time of service. The bill includes several amendments to existing statutes to incorporate these new requirements, particularly adding section 632.848 to the statutes.

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