The bill amends the West Virginia Code to improve the prior authorization process for medical services and medications under the Public Employees Insurance Agency and the Bureau for Medical Services. Key changes include the requirement for electronic submission of prior authorization forms, the establishment of a user-friendly online portal for submissions, and the obligation for timely responses to requests—within five business days for standard requests and two business days for urgent cases. The bill also mandates the maintenance of a comprehensive, science-based list of services and medications requiring prior authorization, which must be updated quarterly. Additionally, it allows for immediate approval of certain prescriptions at discharge for inpatients, provided the medication cost does not exceed $5,000 per day, and exempts high-performing healthcare practitioners from prior authorization requirements for a specified period.

Moreover, the legislation introduces new regulations for health insurers and health maintenance organizations (HMOs), requiring them to accept prior authorization requests through an easily accessible electronic portal. This portal must provide comprehensive information about required prior authorizations and be operational by July 1, 2024. Insurers are required to respond to requests within specified timeframes and establish an appeals process for denied authorizations, including peer reviews. The bill also allows for a three-month carryover of approved prior authorizations across managed care organizations and includes provisions for civil penalties for violations. Overall, the bill aims to streamline the prior authorization process, enhance transparency, and improve patient access to necessary medical services.

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