This bill amends various sections of the Code of West Virginia to improve the prior authorization process for medical services and medications. It expands the definition of "episode of care" to include imaging and rehabilitation, and establishes that prior authorization is required for services or medications exceeding $10,000. The bill mandates electronic submission of prior authorization forms and the creation of a comprehensive portal for tracking requests, which must include a list of services requiring prior authorization and submission instructions. A new "gold card" process is introduced, allowing healthcare practitioners, hospitals, or departments to bypass prior authorization if they meet specific performance criteria, with a standardized process to be implemented by January 1, 2027.

Additionally, the bill revises response time frames for prior authorization requests, requiring decisions within five business days or two business days for urgent cases. It allows approved prior authorizations to carry over to other managed care organizations for three months and increases civil penalties for violations to up to $10,000 per occurrence. The Office of the Insurance Commissioner is tasked with collecting and publishing data on prior authorizations and gold card status, ensuring transparency and compliance. Overall, these amendments aim to streamline the prior authorization process, enhance efficiency in healthcare delivery, and improve access to necessary medical care in West Virginia.

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