ARIZONA STATE SENATE
Fifty-Fifth Legislature, First Regular Session
prior authorization; uniform request forms
Purpose
Requires the Department of Insurance and Financial Institutions (DIFI) to approve separate uniform prior authorization request forms for prescription drugs, devices and durable medical equipment and for all other healthcare procedures, treatments and services by January 1, 2022. Prescribes criteria for the prior authorization request forms.
Background
A prior authorization requirement is a practice implemented by a health care services plan, or its utilization review agent, in which coverage of a health care service is dependent upon approval from the health care services plan before the service is performed, received or prescribed. Prior authorization requirements may include preadmission, pretreatment, prospective or utilization review procedures and does not include case management or step therapy protocols (A.R.S. 20-3401).
A health care plan that contains a prior authorization requirement must: 1) make a list of all prior authorization requirements available to providers; 2) allow providers to access the prior authorization request form through the applicable electronic software system; 3) accept prior authorization requests through a secure electronic transmission; 4) provide at least two forms of access to request a prior authorization; and 5) have emergency after-hours procedures (A.R.S. 20-3403).
There is no anticipated fiscal impact to the state General Fund associated with this legislation.
Provisions
1. Requires DIFI, by January 1, 2022, to approve a uniform prior authorization request form for prescription drug, devices or durable medical equipment and a uniform prior authorization request form for all other health care procedures, treatments and services.
2. Requires DIFI, in approving the uniform prior authorization request forms, to consider:
a) any existing prior authorization request forms that the Centers for Medicare and Medicaid Services or the U.S. Department of Health and Human Services have developed;
b) national standards relating to electronic prior authorization; and
c) forms adopted by the Director of DIFI or another state agency.
3. Requires DIFI, in approving the uniform prior authorization request forms, to seek input from interested stakeholders, including providers, health care service plans, utilization review agents, pharmacists and pharmacy benefit managers.
4. Requires all providers, by January 1, 2023, to use the DIFI-approved uniform prior authorization request forms and requires all health care service plans and utilization review agents to accept and process prior authorization requests submitted using the DIFI-approved prior authorization request forms.
5. Invalidates prior authorization requests that are submitted beginning January 1, 2023, that are not submitted on the DIFI-approved uniform prior authorization request forms.
6. Requires each uniform prior authorization request form to:
a) not exceed two printed pages, excluding provider's notes or documentation submitted in support of a prior authorization request; and
b) meet the prescribed statutory electronic submission and acceptance requirements.
7. Modifies the definition of health care service to be a health care procedure, treatment or service that is covered under a health care services plan, including providing a covered prescription drug, device or durable medical equipment, rather than procedures, treatments or services for the treatment or management of acute pain, chronic pain or opioid use disorder, including prescription drugs, devices or durable medical equipment.
8. Specifies that the uniform prior authorization request form procedures do not prohibit a payor or an entity acting for a payor to use a prior authorization methodology that uses an internet or web-based system if the methodology is consistent with the DIFI-approved uniform prior authorization request forms.
9. Defines terms.
10. Makes technical and conforming changes.
11. Becomes effective on the general effective date.
House Action
HHS 2/1/21 DP 9-0-0-0
3rd Read 2/11/21 60-0-0
Prepared by Senate Research
March 8, 2021
MG/FDR/gs