The bill amends the West Virginia Code to improve the prior authorization process for medical services and medications by requiring the Public Employees Insurance Agency (PEIA) and the Bureau for Medical Services (BMS) to implement an electronic portal for submitting prior authorization requests. This portal will include a comprehensive list of services and medications that require prior authorization and must be easily accessible on insurers' websites and included on insurance cards. The bill mandates timely responses to requests, particularly for urgent cases, and allows for immediate approval of certain inpatient prescriptions at discharge. Additionally, it introduces a "gold card" system that exempts healthcare practitioners who meet performance standards from prior authorization requirements for a defined period.

Moreover, the bill establishes new regulations for health insurers and health maintenance organizations (HMOs) regarding the prior authorization process, including the requirement for electronic submission of prior authorization forms and clear instructions for submitting clinical documentation. It outlines specific timelines for insurers to respond to requests, with expedited timelines for urgent situations, and sets forth procedures for appeals and audits. The bill also allows for a three-month carryover of approved prior authorizations across managed care organizations and mandates the Insurance Commissioner to oversee compliance and data collection. Civil penalties for violations are included to ensure accountability, with the new regulations set to take effect for policies beginning on or after January 1, 2024.

Statutes affected:
Introduced Version: 9-5-32, 33-25A-8s
Committee Substitute: 5-16-7f, 9-5-32, 33-15-4s, 33-16-3dd, 33-24-7s, 33-25-8p
Enrolled Committee Substitute: 5-16-7f, 9-5-32, 33-15-4s, 33-16-3dd, 33-24-7s, 33-25-8p