SB 561-FN is a legislative bill that revises the process of prior authorization for health care services by insurers offering managed care health benefit plans. The bill redefines "clinical review criteria" and introduces new definitions for "prior authorization" and "prior authorization determination," specifying the approval process required before a health care service or prescription drug is covered under a plan. It also updates the definitions of "urgent care," "utilization review," and "utilization review entity." The bill repeals and reenacts RSA 420-J:6, mandating health carriers to have written procedures for utilization review, to develop clinical review criteria with practitioner input, to update these biennially, and to make prior authorization requirements and metrics publicly accessible. Additionally, medical necessity determinations must be made by qualified health care providers licensed in New Hampshire.

The bill sets specific time frames for health carriers to respond to prior authorization requests, with electronic requests requiring a decision within 7 calendar days for non-urgent cases and within 72 hours for urgent cases. Non-electronic requests have a 14-day window for non-urgent cases. If a health carrier fails to notify within these time frames, the prior authorization is deemed approved. The bill also outlines the duration of approval for prior authorization, conditions under which a health carrier is not obligated to pay, and introduces a peer-to-peer review option for providers. It includes changes in legal language, such as replacing "pre-service claim" with "prior authorization determination" and adding a definition for "clinical review criteria." The bill also mandates that medical utilization review entities employ one or more medical directors and sets conditions for payment to health care providers. The effective date of the act is January 1, 2025, and the fiscal impact on the state, county, and local levels is indeterminable.

Statutes affected:
Introduced: 420-J:3, 420-E:1, 420-E:2-a
As Amended by the Senate: 420-J:3, 420-J:5, 420-E:1, 420-E:2-a
Version adopted by both bodies: 420-J:3, 420-J:5, 420-E:1, 420-E:2-a