The bill amends the "Benefit Determination and Utilization Review Act" to ensure that adverse benefit determinations are made by a licensed practitioner with the same licensure as the ordering provider and prohibits retrospective denial of authorization for healthcare services if prior approval was obtained, except under specific circumstances. It introduces a new section on "Step therapy exceptions," requiring insurers to establish a clear process for healthcare professionals to request exceptions to step therapy protocols and respond within specified time frames. The bill also expands the duties of the health insurance commissioner, including making recommendations on administrative expenses and reserve requirements, and establishing an advisory council to address health insurance concerns, particularly for small businesses.

The bill sets forth guidelines to improve the electronic eligibility and coverage verification process, the implementation of coding policies, and the prior authorization process. It emphasizes continuity of care and communication between health plans, providers, and patients, and allows for the use of undisclosed temporary code edits to detect fraud while ensuring transparency in adjudication decisions. The office of the health insurance commissioner is tasked with various responsibilities, including distinguishing between interchangeable products and proprietary medications, encouraging electronic prior authorization, and reporting on healthcare services and insurance coverage. The bill includes insertions granting the office new oversight and enforcement authority, but no deletions from current law are specified in the provided text.

Statutes affected:
7822: 27-18.9-5, 42-14.5-3