Senate Bill 434 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 72 hours for non-urgent services and within 24 hours for urgent services. Additionally, authorizations must remain valid for at least one year and must not be affected by changes in prescription or treatment methods.

The bill also stipulates that if an enrollee transitions to a new health insurance plan, the new utilization review entity must accept prior authorizations from the previous plan for a minimum of 90 days. During this period, the new entity may conduct its own prior authorization review. Furthermore, the bill prohibits denial of payment for services that have received prior authorization unless there is evidence of intentional misrepresentation by the health care provider or if the enrollee was ineligible for coverage at the time of service. The bill includes several amendments to existing statutes and introduces new sections to ensure compliance with these 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