The "Ensuring Transparency in Prior Authorization Act" introduces comprehensive regulations aimed at improving the prior authorization processes utilized by health insurers and contracted utilization review entities. The bill underscores the significance of the patient-physician relationship and seeks to ensure that prior authorization does not obstruct patient care. Key provisions include the requirement for health insurers to publicly disclose their prior authorization criteria on their websites and to promptly notify enrollees and healthcare providers of any changes. Notably, the act prohibits prior authorization requests for medications treating opioid use disorder and establishes strict timelines for insurers to make determinations on health care services, ensuring that authorizations remain valid for one year and are honored for at least 60 days when enrollees switch plans.

Furthermore, the legislation introduces new criteria for health care providers to qualify for exemptions from prior authorization requirements, specifically targeting those with a high approval rate of prior requests. It also clarifies the process for revoking these exemptions, necessitating insurers to provide justifications and an appeal process. The bill amends existing language concerning claim denials based on medical necessity, eliminating vague terms and mandating written explanations for denials, along with the right to review decisions. Additionally, external review organizations are required to evaluate denied claims and communicate their findings within a designated timeframe. The act is scheduled to take effect on July 1, 2024, with certain provisions becoming effective immediately upon passage.

Statutes affected:
24LSO-0068 v0.6: 26-40-102