Assembly Bill 1217 aims to enhance transparency and regulation surrounding prior authorization requirements imposed by health care plans in Wisconsin. The bill mandates that health care plans maintain and publicly publish a comprehensive list of services requiring prior authorization, ensuring that this information is easily accessible without the need for user accounts. Additionally, health care plans must provide at least 60 days' advance written notice to providers before implementing or amending any prior authorization requirements. The bill also stipulates that clinical review criteria used for prior authorization decisions must adhere to nationally recognized standards and be regularly updated to ensure quality care and access to necessary services.

Furthermore, the bill introduces provisions that protect patients and providers from unfair claim denials related to prior authorization. Specifically, it prohibits health care plans from denying claims if the prior authorization requirement was not in effect at the time of service. It also prevents plans from categorizing supplies or services as incidental, which could lead to claim denials. The bill grants the commissioner of insurance the authority to establish rules for exempting certain health care providers from prior authorization requirements based on their approval rates for prior authorization requests. Notably, the bill includes new sections in the statutes, specifically 609.815, 628.42, and 632.848, which outline these requirements and exemptions.

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