(a) (1) (A) A utilization review entity shall disclose all of its prior authorization requirements, clinical criteria, and restrictions in a publicly accessible manner on its website.(B) The disclosure under subdivision (a)(1)(A) of this section shall be explained in detail and in clear and ordinary terms, and include:(i) (a) A list of any healthcare services that require prior authorization. (b) The list under subdivision (a)(1)(B)(i)(a) of this section shall: (1) Be available in a format that can be easily understood by a subscriber and in a machine-readable format that allows for automated retrieval and processing; and (2) Include the following information: (A) The name of the healthcare service and any billing codes associated with the healthcare service; and (B) (i) The effective date and end date of the prior authorization requirement policy for the healthcare service. (ii) A healthcare service that no longer requires a prior authorization shall remain on the list for two (2) years;(ii) (a) Any written clinical criteria for services that require prior authorizations. (b) The information described in subdivision (a)(1)(B)(ii)(a) of this section shall be explained in detail and in clear and ordinary terms; and(iii) Any written clinical criteria for services that do not require prior authorization but are subject to review for medical necessity.(2) (A) Utilization review entities that have agreed, by contract with vendors or third-party administrators, to use licensed, proprietary, or copyrighted protected clinical criteria from the vendors or administrators may satisfy the disclosure requirement under subdivision (a)(1) of this section by making all relevant proprietary clinical criteria available to a healthcare provider that submits a prior authorization request to the utilization review entity through a secured link on the utilization review entity's website that is accessible to the healthcare provider from the public part of its website as long as any link or access restrictions to the information do not cause any delay to the healthcare provider.(B) For out-of-network providers, a utilization review entity may meet the requirements of this subdivision (a)(2) by:(i) Providing the healthcare provider with temporary electronic access in a timely manner to a secure site to review copyright-protected clinical criteria; or(ii) Disclosing copyright-protected clinical criteria in a timely manner to a healthcare provider through other electronic or telephonic means.
(1) (A) A utilization review entity shall disclose all of its prior authorization requirements, clinical criteria, and restrictions in a publicly accessible manner on its website.(B) The disclosure under subdivision (a)(1)(A) of this section shall be explained in detail and in clear and ordinary terms, and include:(i) (a) A list of any healthcare services that require prior authorization. (b) The list under subdivision (a)(1)(B)(i)(a) of this section shall: (1) Be available in a format that can be easily understood by a subscriber and in a machine-readable format that allows for automated retrieval and processing; and (2) Include the following information: (A) The name of the healthcare service and any billing codes associated with the healthcare service; and (B) (i) The effective date and end date of the prior authorization requirement policy for the healthcare service. (ii) A healthcare service that no longer requires a prior authorization shall remain on the list for two (2) years;(ii) (a) Any written clinical criteria for services that require prior authorizations. (b) The information described in subdivision (a)(1)(B)(ii)(a) of this section shall be explained in detail and in clear and ordinary terms; and(iii) Any written clinical criteria for services that do not require prior authorization but are subject to review for medical necessity.
(A) A utilization review entity shall disclose all of its prior authorization requirements, clinical criteria, and restrictions in a publicly accessible manner on its website.
(B) The disclosure under subdivision (a)(1)(A) of this section shall be explained in detail and in clear and ordinary terms, and include:(i) (a) A list of any healthcare services that require prior authorization. (b) The list under subdivision (a)(1)(B)(i)(a) of this section shall: (1) Be available in a format that can be easily understood by a subscriber and in a machine-readable format that allows for automated retrieval and processing; and (2) Include the following information: (A) The name of the healthcare service and any billing codes associated with the healthcare service; and (B) (i) The effective date and end date of the prior authorization requirement policy for the healthcare service. (ii) A healthcare service that no longer requires a prior authorization shall remain on the list for two (2) years;(ii) (a) Any written clinical criteria for services that require prior authorizations. (b) The information described in subdivision (a)(1)(B)(ii)(a) of this section shall be explained in detail and in clear and ordinary terms; and(iii) Any written clinical criteria for services that do not require prior authorization but are subject to review for medical necessity.
(i) (a) A list of any healthcare services that require prior authorization. (b) The list under subdivision (a)(1)(B)(i)(a) of this section shall: (1) Be available in a format that can be easily understood by a subscriber and in a machine-readable format that allows for automated retrieval and processing; and (2) Include the following information: (A) The name of the healthcare service and any billing codes associated with the healthcare service; and (B) (i) The effective date and end date of the prior authorization requirement policy for the healthcare service. (ii) A healthcare service that no longer requires a prior authorization shall remain on the list for two (2) years;
(a) A list of any healthcare services that require prior authorization.
(b) The list under subdivision (a)(1)(B)(i)(a) of this section shall: (1) Be available in a format that can be easily understood by a subscriber and in a machine-readable format that allows for automated retrieval and processing; and (2) Include the following information: (A) The name of the healthcare service and any billing codes associated with the healthcare service; and (B) (i) The effective date and end date of the prior authorization requirement policy for the healthcare service. (ii) A healthcare service that no longer requires a prior authorization shall remain on the list for two (2) years;
(1) Be available in a format that can be easily understood by a subscriber and in a machine-readable format that allows for automated retrieval and processing; and
(2) Include the following information: (A) The name of the healthcare service and any billing codes associated with the healthcare service; and (B) (i) The effective date and end date of the prior authorization requirement policy for the healthcare service. (ii) A healthcare service that no longer requires a prior authorization shall remain on the list for two (2) years;
(A) The name of the healthcare service and any billing codes associated with the healthcare service; and
(B) (i) The effective date and end date of the prior authorization requirement policy for the healthcare service. (ii) A healthcare service that no longer requires a prior authorization shall remain on the list for two (2) years;
(i) The effective date and end date of the prior authorization requirement policy for the healthcare service.
(ii) A healthcare service that no longer requires a prior authorization shall remain on the list for two (2) years;
(ii) (a) Any written clinical criteria for services that require prior authorizations. (b) The information described in subdivision (a)(1)(B)(ii)(a) of this section shall be explained in detail and in clear and ordinary terms; and
(a) Any written clinical criteria for services that require prior authorizations.
(b) The information described in subdivision (a)(1)(B)(ii)(a) of this section shall be explained in detail and in clear and ordinary terms; and
(iii) Any written clinical criteria for services that do not require prior authorization but are subject to review for medical necessity.
(2) (A) Utilization review entities that have agreed, by contract with vendors or third-party administrators, to use licensed, proprietary, or copyrighted protected clinical criteria from the vendors or administrators may satisfy the disclosure requirement under subdivision (a)(1) of this section by making all relevant proprietary clinical criteria available to a healthcare provider that submits a prior authorization request to the utilization review entity through a secured link on the utilization review entity's website that is accessible to the healthcare provider from the public part of its website as long as any link or access restrictions to the information do not cause any delay to the healthcare provider.(B) For out-of-network providers, a utilization review entity may meet the requirements of this subdivision (a)(2) by:(i) Providing the healthcare provider with temporary electronic access in a timely manner to a secure site to review copyright-protected clinical criteria; or(ii) Disclosing copyright-protected clinical criteria in a timely manner to a healthcare provider through other electronic or telephonic means.
(A) Utilization review entities that have agreed, by contract with vendors or third-party administrators, to use licensed, proprietary, or copyrighted protected clinical criteria from the vendors or administrators may satisfy the disclosure requirement under subdivision (a)(1) of this section by making all relevant proprietary clinical criteria available to a healthcare provider that submits a prior authorization request to the utilization review entity through a secured link on the utilization review entity's website that is accessible to the healthcare provider from the public part of its website as long as any link or access restrictions to the information do not cause any delay to the healthcare provider.
(B) For out-of-network providers, a utilization review entity may meet the requirements of this subdivision (a)(2) by:(i) Providing the healthcare provider with temporary electronic access in a timely manner to a secure site to review copyright-protected clinical criteria; or(ii) Disclosing copyright-protected clinical criteria in a timely manner to a healthcare provider through other electronic or telephonic means.
(i) Providing the healthcare provider with temporary electronic access in a timely manner to a secure site to review copyright-protected clinical criteria; or
(ii) Disclosing copyright-protected clinical criteria in a timely manner to a healthcare provider through other electronic or telephonic means.
(b) Before a utilization review entity implements a new or amended prior authorization requirement, clinical criteria, or restriction as described in subdivision (a)(1) of this section, the utilization review entity shall update its website to reflect the new or amended requirement or restriction.
(c) (1) Before implementing a new or amended prior authorization requirement, clinical criteria, or restriction, a utilization review entity shall provide contracted healthcare providers written notice of the new or amended requirement or restriction at least sixty (60) days before implementation of the new or amended requirement or restriction.(2) As used in subdivision (c)(1) of this section, “written notice” means actual notice to the healthcare provider via mail, email, or fax.
(1) Before implementing a new or amended prior authorization requirement, clinical criteria, or restriction, a utilization review entity shall provide contracted healthcare providers written notice of the new or amended requirement or restriction at least sixty (60) days before implementation of the new or amended requirement or restriction.
(2) As used in subdivision (c)(1) of this section, “written notice” means actual notice to the healthcare provider via mail, email, or fax.
(d) (1) A utilization review entity shall make statistics available regarding prior authorization approvals and denials on its website in a readily accessible format.(2) The statistics made available by a utilization review entity under this subsection shall categorize approvals and denials by:(A) Physician specialty;(B) Medication or diagnostic test or procedure;(C) Medical indication offered as justification for the prior authorization request; and(D) Reason for denial.
(1) A utilization review entity shall make statistics available regarding prior authorization approvals and denials on its website in a readily accessible format.
(2) The statistics made available by a utilization review entity under this subsection shall categorize approvals and denials by:(A) Physician specialty;(B) Medication or diagnostic test or procedure;(C) Medical indication offered as justification for the prior authorization request; and(D) Reason for denial.
(A) Physician specialty;
(B) Medication or diagnostic test or procedure;
(C) Medical indication offered as justification for the prior authorization request; and
(D) Reason for denial.
(e) (1) If a utilization review entity provides information to a healthcare provider indicating that a prior authorization is not required for a specific healthcare service, then the utilization review entity shall disclose any other restriction, limitation, or requirement that may preclude coverage of the specific healthcare service, including without limitation:(A) A step therapy requirement;(B) A restriction on the place of the specific healthcare service;(C) A restriction on the healthcare provider type or benefit category;(D) Clinical criteria that completely excludes the specific healthcare service from coverage; and(E) Any post-service review, information request, or audit responsibility that is applicable to the specific healthcare service based on the billing code or category.(2) (A) Subdivision (e)(1) of this section does not apply if a utilization review entity provides a document on the utilization review entity's website or in a format available to download from the utilization review entity's website that includes the following information in an aggregated format:(i) A list of step therapy requirements;(ii) A list of any restrictions on the site of service for a specific healthcare service, to the extent that the restriction deviates from the requirements under Medicare;(iii) A list of any restrictions to the benefit category of a specific healthcare service, to the extent that the restriction deviates from the requirements under Medicare;(iv) A list of any specific healthcare services that are completely excluded from coverage based on clinical criteria; and(v) A list of any specific healthcare services for which the billing code or category requires a post-service review, information request, or audit.(B) The document under subdivision (e)(2)(A) of this section shall include the name of the healthcare service and any billing codes associated with the healthcare service.(C) A utilization review entity shall provide a contracted healthcare provider written notice of any changes to the document under subdivision (e)(2)(A) of this section at least sixty (60) days before implementation of the change via mail, email, or fax.
(1) If a utilization review entity provides information to a healthcare provider indicating that a prior authorization is not required for a specific healthcare service, then the utilization review entity shall disclose any other restriction, limitation, or requirement that may preclude coverage of the specific healthcare service, including without limitation:(A) A step therapy requirement;(B) A restriction on the place of the specific healthcare service;(C) A restriction on the healthcare provider type or benefit category;(D) Clinical criteria that completely excludes the specific healthcare service from coverage; and(E) Any post-service review, information request, or audit responsibility that is applicable to the specific healthcare service based on the billing code or category.
(A) A step therapy requirement;
(B) A restriction on the place of the specific healthcare service;
(C) A restriction on the healthcare provider type or benefit category;
(D) Clinical criteria that completely excludes the specific healthcare service from coverage; and
(E) Any post-service review, information request, or audit responsibility that is applicable to the specific healthcare service based on the billing code or category.
(2) (A) Subdivision (e)(1) of this section does not apply if a utilization review entity provides a document on the utilization review entity's website or in a format available to download from the utilization review entity's website that includes the following information in an aggregated format:(i) A list of step therapy requirements;(ii) A list of any restrictions on the site of service for a specific healthcare service, to the extent that the restriction deviates from the requirements under Medicare;(iii) A list of any restrictions to the benefit category of a specific healthcare service, to the extent that the restriction deviates from the requirements under Medicare;(iv) A list of any specific healthcare services that are completely excluded from coverage based on clinical criteria; and(v) A list of any specific healthcare services for which the billing code or category requires a post-service review, information request, or audit.(B) The document under subdivision (e)(2)(A) of this section shall include the name of the healthcare service and any billing codes associated with the healthcare service.(C) A utilization review entity shall provide a contracted healthcare provider written notice of any changes to the document under subdivision (e)(2)(A) of this section at least sixty (60) days before implementation of the change via mail, email, or fax.
(A) Subdivision (e)(1) of this section does not apply if a utilization review entity provides a document on the utilization review entity's website or in a format available to download from the utilization review entity's website that includes the following information in an aggregated format:(i) A list of step therapy requirements;(ii) A list of any restrictions on the site of service for a specific healthcare service, to the extent that the restriction deviates from the requirements under Medicare;(iii) A list of any restrictions to the benefit category of a specific healthcare service, to the extent that the restriction deviates from the requirements under Medicare;(iv) A list of any specific healthcare services that are completely excluded from coverage based on clinical criteria; and(v) A list of any specific healthcare services for which the billing code or category requires a post-service review, information request, or audit.
(i) A list of step therapy requirements;
(ii) A list of any restrictions on the site of service for a specific healthcare service, to the extent that the restriction deviates from the requirements under Medicare;
(iii) A list of any restrictions to the benefit category of a specific healthcare service, to the extent that the restriction deviates from the requirements under Medicare;
(iv) A list of any specific healthcare services that are completely excluded from coverage based on clinical criteria; and
(v) A list of any specific healthcare services for which the billing code or category requires a post-service review, information request, or audit.
(B) The document under subdivision (e)(2)(A) of this section shall include the name of the healthcare service and any billing codes associated with the healthcare service.
(C) A utilization review entity shall provide a contracted healthcare provider written notice of any changes to the document under subdivision (e)(2)(A) of this section at least sixty (60) days before implementation of the change via mail, email, or fax.