Senate Bill 1163 aims to enhance transparency and regulation surrounding prior authorization requirements imposed by health care plans. 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, it requires plans to 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 providers and enrollees 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 the service was provided. 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 the insertion of new sections into the statutes, including 609.815, 628.42, and 632.848, which outline these new 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