SB 602: Insurance; prior authorization and utilization review requirements for healthcare plans; reform

Senate Bill 602

By: Senators Parkes of the 7th, Mangham of the 55th, James of the 28th, Kemp of the 38th and Harrell of the 40th

A BILL TO BE ENTITLED

AN ACT

To amend Article 2 of Chapter 46 of Title 33 of the Official Code of Georgia Annotated, relating to prior authorization, so as to reform prior authorization and utilization review requirements for healthcare plans; to provide for certain information to be provided to healthcare providers at the time of notification of an adverse determination; to provide for aggregate statistics of certain data; to provide for the Commissioner of Insurance to summarize and report certain data; to provide for specific criteria as part of an insurer's program not requiring prior authorizations under certain conditions; to provide for definitions; to limit documentation for utilization review; to provide for technology requirements for utilization review; to provide for prior authorizations to remain valid; to provide for retroactive authorizations; to exempt certain healthcare services from prior authorization; to revise prior authorization time responses; to provide for automatic authorization; to provide for the chapter construction; to provide for related matters; to provide for an effective date and applicability; to repeal conflicting laws; and for other purposes.

BE IT ENACTED BY THE GENERAL ASSEMBLY OF GEORGIA:

SECTION 1.

Article 2 of Chapter 46 of Title 33 of the Official Code of Georgia Annotated, relating to prior authorizations, is amended by revising Code Section 33-46-20, relating to prior authorization requirements posted on website and statistical reporting, as follows:

"33-46-20.

(a) An insurer shall make any current prior authorization requirements readily accessible on its website to healthcare providers. Clinical criteria on which an adverse determination is based shall be provided to the healthcare provider at At the time of the notification of an adverse determination, the healthcare provider shall be provided:

(1) The clinical criteria on which the adverse determination is based;

(2) Detailed reasoning for such determination;

(3) The national provider identifier, credentials, specialty, and board certification of the reviewing physician; and

(4) The healthcare provider's rights and procedures for appeal.

(b) If an insurer intends either to implement a new prior authorization requirement or to amend an existing requirement, such insurer shall ensure that the new or amended requirement is not implemented unless such insurer's website has been updated to reflect such addition or change. An insurer shall not retroactively deny coverage for a healthcare service that received prior authorization.

(c) An insurer using prior authorization shall make aggregate statistics available per such insurer and per its plans regarding prior authorization approvals and denials on its website in a readily accessible format. The Commissioner shall determine the statistics required in order to comply with this Code section in accordance with applicable state and federal privacy laws. Such statistics shall include, but not be limited to, the following:

(1) Approved or denied on The total number of initial requests for prior authorization, whether each initial request was approved or denied, and the approval and denial rates;

(2) Reason for denial;

(3) Whether appealed and the appeal rates;

(4) Whether approved or denied on appeal and the approval and denial rates; and

(5) Time between submission and response and the average response times;

(6) Whether the prior authorization, adverse determination, or appeal procedure was compliant with time requirements of this chapter; and

(7) Whether the prior authorization, adverse determination, or appeal procedure was compliant with procedural requirements of this chapter.

(d) The Commissioner shall include a summary of the prior authorization data required under this Code section in the annual report required under Code Section 33-49-16."

SECTION 2.

Said article is further amended by revising subsection (b) of Code Section 33-46-20.1, relating to program of selective application of reductions in prior authorization requirements, as follows:

"(b) Criteria for participation by healthcare providers and the healthcare services included in the program shall be at the discretion of the insurer; provided, however, that such each insurer shall include in the program a provision under which such insurer shall not require prior authorization from a healthcare provider for a specific healthcare service if, in the prior 12 month period, the insurer has approved not less than 80 percent of such healthcare provider's prior authorization requests for such healthcare service. Such exemption shall remain in effect for not less than 12 months, unless the insurer determines there has been fraud or material misrepresentation. Each insurer shall submit to the department a filing concerning such program. Such filing shall include a full narrative description of the program, the criteria for participation in the program, a list of the procedures and services subject to the program, the number of healthcare providers participating in the program, and any other information deemed necessary by the department."

SECTION 3.

Said article is further amended by revising subsection (d) and adding new subsections to Code Section 33-46-21, relating to insurer responsibility for compliance, periodic reviews, and evaluation of adverse determinations, to read as follows: "(d) As used in this subsection, the term 'qualified healthcare provider' shall have the same meaning as set forth in Code Section 33-46-22. Qualified healthcare professionals providers shall administer the utilization review program and oversee utilization review decisions. An initial screening of prior authorization requests may be completed without providing the treating provider or other qualified healthcare professional provider with the opportunity to speak with a clinical peer of the private review agent or utilization review entity. Such an opportunity shall be provided, however, before an appeal. If a private review agent or utilization review entity questions the medical necessity of a healthcare service, such agent or entity shall notify the covered person's treating provider, or such provider's appropriately qualified designee familiar with the patient's case, that medical necessity is being questioned in accordance with the provisions of paragraph (5) of subsection (a) of Code Section 33-46-6."

"(f) Any documentation requests under the utilization review program shall be limited to information reasonably necessary to establish medical necessity. Duplicative and irrelevant documentation shall not be required.

(g) Any utilization review program shall accept and respond to prior authorization requests through secured electronic transmission standards for pharmacy transactions. Technology not integrated into a healthcare provider's electronic health record shall not be deemed compliant."

SECTION 4.

Said article is further amended by revising Code Section 33-46-22, relating to review of appeals by appropriate healthcare provider, as follows:

"33-46-22.

A private review agent or utilization review entity shall ensure that all adverse determinations are made and all appeals of adverse determinations are reviewed by an appropriate a qualified healthcare provider provider. As used in this Code section, the term 'qualified healthcare provider' means a licensed physician who shall:

(1) Possess a current and valid nonrestricted license or maintain other appropriate legal authorization;

(2) Be currently in active practice in the same or similar specialty and who typically manages the medical condition or disease;

(3) Be knowledgeable of, and have experience providing, the healthcare service under appeal;

(4) Not have been directly involved in making the adverse determination; and

(5) Consider all known clinical aspects of the healthcare service under review, including, but not limited to, a review of all pertinent medical or other records provided to the private review agent or utilization review entity by the covered person's healthcare provider, any relevant records provided to such agent or entity by a facility, and any medical or other literature provided to such agent or entity by the healthcare provider."

SECTION 5.

Said article is further amended by revising Code Section 33-46-23, relating to restrictions on authorizations when service timely rendered, as follows:

"33-46-23.

(a) If initial healthcare services are performed within 45 business days one year of approval of prior authorization, the insurer shall not revoke, limit, condition, or restrict such authorization, unless such prior authorization is for a Schedule II controlled substance or there is a billing error, fraud, material misrepresentation, or loss of coverage.

(b) Except for ongoing medication therapy of chronic conditions as provided for in Code Section 33-46-23.1, a prior authorization of a healthcare service shall remain valid for the lesser of one year from the date the healthcare provider receives prior authorization, the duration of the treatment of the condition of the covered person, or until the last day of coverage under the covered person's healthcare plan, unless there is fraud or material misrepresentation."

SECTION 6.

Said article is further amended by adding a new Code section to read as follows:

"33-46-23.2.

(a) As used in this Code section, the term 'retroactive authorization' means any written or oral determination made by a claim administrator or an insurer, or any agent thereof, after a covered person's receipt of a healthcare service that such service is a covered benefit under the applicable plan and that any requirement of medical necessity or other requirements imposed by such plan as prerequisites for payment for such service are satisfied. The term 'agent' as used in this subsection shall not include an agent or agency as defined in Code Section 33-23-1.

(b) A healthcare provider may submit a request for a retroactive authorization for a healthcare service within ten days of rendering such service.

(c) A claim for coverage of a healthcare service shall not be denied solely for a healthcare provider's failure to obtain prior authorization."

SECTION 7.

Said article is further amended by revising Code Section 23-46-24, relating to medically necessary unanticipated emergency or urgent healthcare services, as follows:

"33-46-24.

(a) Prior authorization shall not be required for unanticipated emergency healthcare services, urgent healthcare services, or covered healthcare services which are incidental to the primary covered healthcare service and determined by the covered person's physician or dentist to be medically necessary.

(b) Prior authorization shall not be required for medications for opioid use disorder for a covered person under a healthcare plan."

SECTION 8.

Said article is further amended by revising Code Section 33-46-26, relating to timely notification of prior authorization or adverse determination, as follows:

"33-46-26.

Effective January 1, 2022, until December 31, 2022, if an insurer requires prior authorization of a healthcare service, a private review agent or utilization review entity shall notify the covered person's healthcare provider, or such provider's appropriately qualified designee, of any prior authorization or adverse determination within 15 calendar days of obtaining all necessary information to make such authorization or adverse determination. Effective January 1, 2023, if an insurer requires prior authorization of a healthcare service, a private review agent or utilization review entity shall notify the covered person's healthcare provider, or such provider's appropriately qualified designee, of any prior authorization or adverse determination within 7 calendar days 48 hours of obtaining all necessary information to make such authorization or adverse determination."

SECTION 9.

Said article is further amended by revising Code Section 33-46-27, relating to notification time for prior authorization or adverse determination, as follows:

"33-46-27.

A private review agent or utilization review entity shall render a prior authorization or adverse determination concerning urgent healthcare services and notify such person's healthcare provider, or such provider's appropriately qualified designee, of that prior authorization or adverse determination no later than 72 hours 24 hours after receiving all information needed to complete the review of the requested healthcare services."

SECTION 10.

Said article is further amended by revising subsection (a) of Code Section 33-46-28, relating to honoring prior authorizations, as follows:

"(a) Upon receipt of information documenting a prior authorization from a covered person or from a covered person's healthcare provider, a private review agent or utilization review entity, for at least the initial 30 90 days of such person's new coverage, shall honor a prior authorization for a covered healthcare service granted to him or her from a previous private review agent or utilization review entity even if approval criteria or products of a healthcare plan have changed or such person is covered under a new healthcare plan, so long as the former criteria, products, or plans are not binding upon a new insurer."

SECTION 11.

Said article is further amended by revising Code Section 33-46-29, relating to noncompliance resulting in automatic authorization, as follows:

"33-46-29.

Each violation by a private review agent or utilization review entity of deadline or other requirements specified in this chapter shall result in the automatic authorization of healthcare services under review by such private review agent or utilization review entity if such noncompliance is related to such services. Notwithstanding the foregoing, noncompliance based on a de minimis violation that does not cause, or is not likely to cause, prejudice or harm to the covered person shall not result in the automatic authorization of such healthcare services, so long as the insurer demonstrates that the violation occurred due to good cause or due to matters beyond the control of the insurer and that such violation occurred in the context of an ongoing good faith exchange of information between the insurer and the covered person, or, if applicable, the covered person's healthcare provider or authorized representative."

SECTION 12.

Said article is further amended by revising Code Section 33-46-32, relating to Commissioner's authority not reduced, as follows:

"33-46-32.

Nothing in this chapter shall be construed as:

(1) Mandating coverage of any specific healthcare service;

(2) Granting the Commissioner authority to determine covered benefits;

(3) Altering the medical necessity standards of a healthcare plan, except as expressly provided;

(4) Reducing the Commissioner's authority, including, but not limited to, conducting market conduct examinations and imposing monetary penalties for violations of any provisions of this title; or

(5) Reducing reducing the authority of the commissioner of community health."

SECTION 13.

This Act shall become effective on January 1, 2027, and shall apply to all policies or contracts issued, delivered, issued for delivery, or renewed in this state on or after such date.

SECTION 14.

All laws and parts of laws in conflict with this Act are repealed.