SB602: SB602 Insurance; prior authorization and utilization review requirements for healthcare plans; reform

26 LC 52 1033 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 Co de of Georgia Annotated,1 relating to prior authorization, so as to reform prior authoriz ation and utilization review2 requirements for healthcare plans; to provide for certain infor mation to be provided to3 healthcare providers at the time of notification of an adverse determination; to provide for4 aggregate statistics of certain data; to provide for the Commis sioner of Insurance to5 summarize and report certain data; to provide for specific crit eria as part of an insurer's6 program not requiring prior authorizations under certain condit ions; to provide for7 definitions; to limit documentation for utilization review; to provide for technology8 requirements for utilization review; to provide for prior autho rizations to remain valid; to9 provide for retroactive authorizations; to exempt certain healt hcare services from prior10 authorization; to revise prior authorization time responses; to provide for automatic11 authorization; to provide for the chapter construction; to prov ide for related matters; to12 provide for an effective date and applicability; to repeal conf licting laws; and for other13 purposes.14 BE IT ENACTED BY THE GENERAL ASSEMBLY OF GEORGIA:15 S. B. 602 - 1 - 26 LC 52 1033 SECTION 1.16 Article 2 of Chapter 46 of Title 33 of the Official Code of Geo rgia Annotated, relating to17 prior authorizations, is amended by revising Code Section 33-46 -20, relating to prior18 authorization requirements posted on website and statistical reporting, as follows:19 "33-46-20.20 (a) An insurer shall make any current prior authorization requirements readily accessible21 on its website to healthcare providers. Clinical criteria on which an adverse determination22 is based shall be provided to the healthcare provider at At the time of the notification of an23 adverse determination, the healthcare provider shall be provided:24 (1) The clinical criteria on which the adverse determination is based;25 (2) Detailed reasoning for such determination;26 (3) The national provider identifier, credentials, specialty, and board certification of the27 reviewing physician; and28 (4) The healthcare provider's rights and procedures for appeal.29 (b) If an insurer intends either to implement a new prior authorization requirement or to30 amend an existing requirement, such insurer shall ensure that t he new or amended31 requirement is not implemented unless such insurer's website has been updated to reflect32 such addition or change. An insurer shall not retroactively deny coverage for a healthcare33 service that received prior authorization.34 (c) An insurer using prior authorization shall make aggregate statistics available per such35 insurer and per its plans regarding prior authorization approvals and denials on its website36 in a readily accessible format. The Commissioner shall determine the statistics required37 in order to comply with this Code section in accordance with applicable state and federal38 privacy laws. Such statistics shall include, but not be limited to, the following:39 (1) Approved or denied on The total number of initial requests for prior authorization,40 whether each initial request was approved or denied, and the approval and denial rates;41 (2) Reason for denial;42 S. B. 602 - 2 - 26 LC 52 1033 (3) Whether appealed and the appeal rates;43 (4) Whether approved or denied on appeal and the approval and denial rates; and44 (5) Time between submission and response and the average response times;45 (6) Whether the prior authorization, adverse determination, or appeal procedure was46 compliant with time requirements of this chapter; and47 (7) Whether the prior authorization, adverse determination, or appeal procedure was48 compliant with procedural requirements of this chapter.49 (d) The Commissioner shall include a summary of the prior auth orization data required50 under this Code section in the annual report required under Code Section 33-49-16." 51 SECTION 2.52 Said article is further amended by revising subsection (b) of C ode Section 33-46-20.1,53 relating to program of selective application of reductions in prior authorization requirements,54 as follows:55 "(b) Criteria for participation by healthcare providers and the healthcare services included56 in the program shall be at the discretion of the insurer; provided, however, that such each57 insurer shall include in the program a provision under which such insurer shall not require58 prior authorization from a healthcare provider for a specific h ealthcare service if, in the59 prior 12 month period, the insurer has approved not less than 80 percent of such healthcare60 provider's prior authorization requests for such healthcare service. Such exemption shall61 remain in effect for not less than 12 months, unless the insurer determines there has been62 fraud or material misrepresentation. Each insurer shall submit to the department a filing63 concerning such program. Such filing shall include a full narr ative description of the64 program, the criteria for participation in the program, a list of the procedures and services65 subject to the program, the number of healthcare providers part icipating in the program,66 and any other information deemed necessary by the department."67 S. B. 602 - 3 - 26 LC 52 1033 SECTION 3.68 Said article is further amended by revising subsection (d) and adding new subsections to69 Code Section 33-46-21, relating to insurer responsibility for compliance, periodic reviews,70 and evaluation of adverse determinations, to read as follows:71 "(d) As used in this subsection, the term 'qualified healthcare provider' shall have the same72 meaning as set forth in Code Section 33-46-22. Qualified healthcare professionals73 providers shall administer the utilization review program and oversee ut ilization review74 decisions. An initial screening of prior authorization requests may be completed without75 providing the treating provider or other qualified healthcare professional provider with the76 opportunity to speak with a clinical peer of the private review agent or utilization review77 entity. Such an opportunity shall be provided, however, before an appeal. If a private78 review agent or utilization review entity questions the medical necessity of a healthcare79 service, such agent or entity shall notify the covered person's treating provider, or such80 provider's appropriately qualified designee familiar with the p atient's case, that medical81 necessity is being questioned in accordance with the provisions of paragraph (5) of82 subsection (a) of Code Section 33-46-6."83 "(f) Any documentation requests under the utilization review program shall be limited to84 information reasonably necessary to establish medical necessity. Duplicative and irrelevant85 documentation shall not be required.86 (g) Any utilization review program shall accept and respond to prior authorization requests87 through secured electronic transmission standards for pharmacy transactions. Technology88 not integrated into a healthcare provider's electronic health r ecord shall not be deemed89 compliant."90 SECTION 4.91 Said article is further amended by revising Code Section 33-46- 22, relating to review of92 appeals by appropriate healthcare provider, as follows:93 S. B. 602 - 4 - 26 LC 52 1033 "33-46-22.94 A private review agent or utilization review entity shall ensur e that all adverse95 determinations are made and all appeals of adverse determinations are reviewed by an96 appropriate a qualified healthcare provider provider. As used in this Code section, the term97 'qualified healthcare provider' means a licensed physician who shall:98 (1) Possess a current and valid nonrestricted license or maintain other appropriate legal99 authorization;100 (2) Be currently in active practice in the same or similar spe cialty and who typically101 manages the medical condition or disease;102 (3) Be knowledgeable of, and have experience providing, the healthcare service under103 appeal;104 (4) Not have been directly involved in making the adverse determination; and105 (5) Consider all known clinical aspects of the healthcare service under review, including,106 but not limited to, a review of all pertinent medical or other records provided to the107 private review agent or utilization review entity by the covere d person's healthcare108 provider, any relevant records provided to such agent or entity by a facility, and any109 medical or other literature provided to such agent or entity by the healthcare provider."110 111 SECTION 5.112 Said article is further amended by revising Code Section 33-46-23, relating to restrictions on113 authorizations when service timely rendered, as follows:114 "33-46-23.115 (a) If initial healthcare services are performed within 45 business days one year o f116 approval of prior authorization, the insurer shall not revoke, limit, condition, or restrict117 such authorization, unless such prior authorization is for a Schedule II controlled substance118 or there is a billing error, fraud, material misrepresentation, or loss of coverage.119 S. B. 602 - 5 - 26 LC 52 1033 (b) Except for ongoing medication therapy of chronic conditions as provided for in Code120 Section 33-46-23.1, a prior authorization of a healthcare service shall remain valid for the121 lesser of one year from the date the healthcare provider receiv es prior authorization, the122 duration of the treatment of th e condition of the covered person, or until the last day of123 coverage under the covered person's healthcare plan, unless the re is fraud or material124 misrepresentation."125 SECTION 6.126 Said article is further amended by adding a new Code section to read as follows:127 "33-46-23.2.128 (a) As used in this Code section, the term 'retroactive authorization' means any written or129 oral determination made by a claim administrator or an insurer, or any agent thereof, after130 a covered person's receipt of a healthcare service that such se rvice is a covered benefit131 under the applicable plan and that any requirement of medical n ecessity or other132 requirements imposed by such plan as prerequisites for payment for such service are133 satisfied. The term 'agent' as used in this subsection shall not include an agent or agency134 as defined in Code Section 33-23-1.135 (b) A healthcare provider may submit a request for a retroacti ve authorization for a136 healthcare service within ten days of rendering such service.137 (c) A claim for coverage of a healthcare service shall not be denied solely for a healthcare138 provider's failure to obtain prior authorization."139 SECTION 7.140 Said article is further amended by revising Code Section 23-46- 24, relating to medically141 necessary unanticipated emergency or urgent healthcare services, as follows:142 S. B. 602 - 6 - 26 LC 52 1033 "33-46-24.143 (a) Prior authorization shall not be required for unanticipated e mergency healthcare144 services, urgent healthcare services, or covered healthcare services which are incidental145 to the primary covered healthcare service and determined by the covered person's physician146 or dentist to be medically necessary.147 (b) Prior authorization shall not be required for medications for opioid use disorder for a148 covered person under a healthcare plan."149 SECTION 8.150 Said article is further amended by revising Code Section 33-46- 26, relating to timely151 notification of prior authorization or adverse determination, as follows:152 "33-46-26.153 Effective January 1, 2022, until December 31, 2022, if an insur er requires prior154 authorization of a healthcare service, a private review agent o r utilization review entity155 shall notify the covered person's healthcare provider, or such provider's appropriately156 qualified designee, of any prior authorization or adverse determination within 15 calendar157 days of obtaining all necessary information to make such author ization or adverse158 determination. Effective January 1, 2023, if an insurer requir es prior authorization of a159 healthcare service, a private review agent or utilization revie w entity shall notify the160 covered person's healthcare provider, or such provider's appropriately qualified designee,161 of any prior authorization or adverse determination within 7 ca lendar days 48 hours of162 obtaining all necessary information to make such authorization or adverse determination."163 SECTION 9.164 Said article is further amended by revising Code Section 33-46-27, relating to notification165 time for prior authorization or adverse determination, as follows:166 S. B. 602 - 7 - 26 LC 52 1033 "33-46-27.167 A private review agent or utilization review entity shall rende r a prior authorization or168 adverse determination concerning urgent healthcare services and notify such person's169 healthcare provider, or such provider's appropriately qualified designee, of that prior170 authorization or adverse determination no later than 72 hours 24 hours after receiving all171 information needed to complete the review of the requested healthcare services."172 SECTION 10.173 Said article is further amended by revising subsection (a) of Code Section 33-46-28, relating174 to honoring prior authorizations, as follows:175 "(a) Upon receipt of information documenting a prior authorization from a covered person176 or from a covered person's healthcare provider, a private review agent or utilization review177 entity, for at least the initial 30 90 days of such person's new coverage, shall honor a prior178 authorization for a covered healthcare service granted to him or her from a previous private179 review agent or utilization review entity even if approval crit eria or products of a180 healthcare plan have changed or such person is covered under a new healthcare plan, so181 long as the former criteria, products, or plans are not binding upon a new insurer."182 SECTION 11.183 Said article is further amended by revising Code Section 33-46-29, relating to noncompliance184 resulting in automatic authorization, as follows:185 "33-46-29.186 Each violation by a private review agent or utilization review entity of deadline or other187 requirements specified in this chapter shall result in the auto matic authorization of188 healthcare services under review by such private review agent or utilization review entity189 if such noncompliance is related to such services. Notwithstan ding the foregoing,190 noncompliance based on a de minimis violation that does not cau se, or is not likely to191 S. B. 602 - 8 - 26 LC 52 1033 cause, prejudice or harm to the covered person shall not result in the automatic192 authorization of such healthcare services, so long as the insur er demonstrates that the193 violation occurred due to good cause or due to matters beyond t he control of the insurer194 and that such violation occurred in the context of an ongoing g ood faith exchange of 195 information between the insurer and the covered person, or, if applicable, the covered196 person's healthcare provider or authorized representative."197 SECTION 12.198 Said article is further amended by revising Code Section 33-46- 32, relating to199 Commissioner's authority not reduced, as follows:200 "33-46-32.201 Nothing in this chapter shall be construed as: 202 (1) Mandating coverage of any specific healthcare service;203 (2) Granting the Commissioner authority to determine covered benefits;204 (3) Altering the medical necessity standards of a healthcare p lan, except as expressly205 provided;206 (4) Reducing the Commissioner's authority, including, but not limited to, conducting207 market conduct examinations and imposing monetary penalties for violations of any208 provisions of this title; or209 (5) Reducing reducing the authority of the commissioner of community health."210 SECTION 13.211 This Act shall become effective on January 1, 2027, and shall a pply to all policies or212 contracts issued, delivered, issued for delivery, or renewed in this state on or after such date.213 SECTION 14.214 All laws and parts of laws in conflict with this Act are repealed.215 S. B. 602 - 9 -