(a) (1) For any provision of this subchapter that relates to a specific request from a healthcare provider for a prior authorization, if a healthcare insurer or utilization review entity fails to comply with this subchapter, the requested healthcare services shall be deemed authorized or approved.(2) Within two (2) days after a healthcare provider provides notice that the healthcare insurer or utilization review entity has failed to comply with this subchapter, the healthcare insurer or utilization review entity shall:(A) Issue the authorization for the requested healthcare service;(B) Resend to a healthcare provider any request for information previously sent to, and unanswered by, the healthcare provider; or(C) (i) Refer the matter to the State Insurance Department for review.(ii) If the matter is referred to the department under subdivision (a)(2)(C)(i) of this section, then after notice to the healthcare insurer or utilization review entity, the Insurance Commissioner may conduct an investigation and hold a hearing under § 23-66-209, to determine whether or not the healthcare insurer or utilization review entity failed to comply with this subchapter.(iii) If the commissioner finds that the healthcare insurer or utilization review entity failed to comply with this subchapter, then the commissioner may order the healthcare insurer or utilization review entity to:(a) Issue the authorization for the requested healthcare service;(b) Pay the costs of a hearing; and(c) (1) Pay a monetary penalty as described in § 23-66-210(a)(1) of not more than one thousand dollars ($1,000) for each violation, not to exceed an aggregate penalty of ten thousand dollars ($10,000), unless the person knew or reasonably should have known he or she was in violation of this subchapter.(2) If a person knew or reasonably should have known he or she was in violation of this subchapter, the penalty under subdivision (a)(2)(C)(iii)(c)(1) of this section shall not be more than five thousand dollars ($5,000) for each violation, not to exceed an aggregate penalty amount of fifty thousand dollars ($50,000) in any six-month period.(iv) If the commissioner finds that a healthcare insurer or utilization review entity has complied with this subchapter, then the commissioner and the department shall provide notice to:(a) The healthcare insurer or utilization review entity; and(b) The requesting healthcare provider.
(1) For any provision of this subchapter that relates to a specific request from a healthcare provider for a prior authorization, if a healthcare insurer or utilization review entity fails to comply with this subchapter, the requested healthcare services shall be deemed authorized or approved.
(2) Within two (2) days after a healthcare provider provides notice that the healthcare insurer or utilization review entity has failed to comply with this subchapter, the healthcare insurer or utilization review entity shall:(A) Issue the authorization for the requested healthcare service;(B) Resend to a healthcare provider any request for information previously sent to, and unanswered by, the healthcare provider; or(C) (i) Refer the matter to the State Insurance Department for review.(ii) If the matter is referred to the department under subdivision (a)(2)(C)(i) of this section, then after notice to the healthcare insurer or utilization review entity, the Insurance Commissioner may conduct an investigation and hold a hearing under § 23-66-209, to determine whether or not the healthcare insurer or utilization review entity failed to comply with this subchapter.(iii) If the commissioner finds that the healthcare insurer or utilization review entity failed to comply with this subchapter, then the commissioner may order the healthcare insurer or utilization review entity to:(a) Issue the authorization for the requested healthcare service;(b) Pay the costs of a hearing; and(c) (1) Pay a monetary penalty as described in § 23-66-210(a)(1) of not more than one thousand dollars ($1,000) for each violation, not to exceed an aggregate penalty of ten thousand dollars ($10,000), unless the person knew or reasonably should have known he or she was in violation of this subchapter.(2) If a person knew or reasonably should have known he or she was in violation of this subchapter, the penalty under subdivision (a)(2)(C)(iii)(c)(1) of this section shall not be more than five thousand dollars ($5,000) for each violation, not to exceed an aggregate penalty amount of fifty thousand dollars ($50,000) in any six-month period.(iv) If the commissioner finds that a healthcare insurer or utilization review entity has complied with this subchapter, then the commissioner and the department shall provide notice to:(a) The healthcare insurer or utilization review entity; and(b) The requesting healthcare provider.
(A) Issue the authorization for the requested healthcare service;
(B) Resend to a healthcare provider any request for information previously sent to, and unanswered by, the healthcare provider; or
(C) (i) Refer the matter to the State Insurance Department for review.(ii) If the matter is referred to the department under subdivision (a)(2)(C)(i) of this section, then after notice to the healthcare insurer or utilization review entity, the Insurance Commissioner may conduct an investigation and hold a hearing under § 23-66-209, to determine whether or not the healthcare insurer or utilization review entity failed to comply with this subchapter.(iii) If the commissioner finds that the healthcare insurer or utilization review entity failed to comply with this subchapter, then the commissioner may order the healthcare insurer or utilization review entity to:(a) Issue the authorization for the requested healthcare service;(b) Pay the costs of a hearing; and(c) (1) Pay a monetary penalty as described in § 23-66-210(a)(1) of not more than one thousand dollars ($1,000) for each violation, not to exceed an aggregate penalty of ten thousand dollars ($10,000), unless the person knew or reasonably should have known he or she was in violation of this subchapter.(2) If a person knew or reasonably should have known he or she was in violation of this subchapter, the penalty under subdivision (a)(2)(C)(iii)(c)(1) of this section shall not be more than five thousand dollars ($5,000) for each violation, not to exceed an aggregate penalty amount of fifty thousand dollars ($50,000) in any six-month period.(iv) If the commissioner finds that a healthcare insurer or utilization review entity has complied with this subchapter, then the commissioner and the department shall provide notice to:(a) The healthcare insurer or utilization review entity; and(b) The requesting healthcare provider.
(i) Refer the matter to the State Insurance Department for review.
(ii) If the matter is referred to the department under subdivision (a)(2)(C)(i) of this section, then after notice to the healthcare insurer or utilization review entity, the Insurance Commissioner may conduct an investigation and hold a hearing under § 23-66-209, to determine whether or not the healthcare insurer or utilization review entity failed to comply with this subchapter.
(iii) If the commissioner finds that the healthcare insurer or utilization review entity failed to comply with this subchapter, then the commissioner may order the healthcare insurer or utilization review entity to:(a) Issue the authorization for the requested healthcare service;(b) Pay the costs of a hearing; and(c) (1) Pay a monetary penalty as described in § 23-66-210(a)(1) of not more than one thousand dollars ($1,000) for each violation, not to exceed an aggregate penalty of ten thousand dollars ($10,000), unless the person knew or reasonably should have known he or she was in violation of this subchapter.(2) If a person knew or reasonably should have known he or she was in violation of this subchapter, the penalty under subdivision (a)(2)(C)(iii)(c)(1) of this section shall not be more than five thousand dollars ($5,000) for each violation, not to exceed an aggregate penalty amount of fifty thousand dollars ($50,000) in any six-month period.
(a) Issue the authorization for the requested healthcare service;
(b) Pay the costs of a hearing; and
(c) (1) Pay a monetary penalty as described in § 23-66-210(a)(1) of not more than one thousand dollars ($1,000) for each violation, not to exceed an aggregate penalty of ten thousand dollars ($10,000), unless the person knew or reasonably should have known he or she was in violation of this subchapter.(2) If a person knew or reasonably should have known he or she was in violation of this subchapter, the penalty under subdivision (a)(2)(C)(iii)(c)(1) of this section shall not be more than five thousand dollars ($5,000) for each violation, not to exceed an aggregate penalty amount of fifty thousand dollars ($50,000) in any six-month period.
(1) Pay a monetary penalty as described in § 23-66-210(a)(1) of not more than one thousand dollars ($1,000) for each violation, not to exceed an aggregate penalty of ten thousand dollars ($10,000), unless the person knew or reasonably should have known he or she was in violation of this subchapter.
(2) If a person knew or reasonably should have known he or she was in violation of this subchapter, the penalty under subdivision (a)(2)(C)(iii)(c)(1) of this section shall not be more than five thousand dollars ($5,000) for each violation, not to exceed an aggregate penalty amount of fifty thousand dollars ($50,000) in any six-month period.
(iv) If the commissioner finds that a healthcare insurer or utilization review entity has complied with this subchapter, then the commissioner and the department shall provide notice to:(a) The healthcare insurer or utilization review entity; and(b) The requesting healthcare provider.
(a) The healthcare insurer or utilization review entity; and
(b) The requesting healthcare provider.
(b) A healthcare service that is authorized or approved under subsection (a) of this section is not subject to audit recoupment under § 23-63-1801 et seq.
(c) (1) For any provision of this subchapter not subject to subsection (a) of this section, if a healthcare insurer or utilization review entity fails to comply with this subchapter, a healthcare provider may provide notice to the healthcare insurer or utilization review entity of the failure to comply.(2) Within (1) business day after a healthcare provider provides notice that the healthcare insurer or utilization review entity has failed to comply with this subchapter, the healthcare insurer or utilization review entity shall:(A) Take action to address the failure retrospectively and prospectively to ensure compliance; or(B) (i) Refer the matter to the department for review.(ii) If the matter is referred to the department under subdivision (c)(2)(B)(i) of this section or by a complaint filed by a healthcare provider or a subscriber, the commissioner may conduct an investigation and hold a hearing under § 23-66-209 to determine whether or not the healthcare insurer or utilization review entity failed to comply with this subchapter with such frequency as to indicate a general business practice.(iii) If the commissioner finds that the healthcare insurer or utilization review entity failed to comply with this subchapter with such frequency as to indicate a general business practice, then the commissioner shall order the healthcare insurer or utilization review entity to: (a) Take action to address the failure retrospectively and prospectively to ensure compliance; and (b) Pay a civil fine not to exceed five thousand dollars ($5,000) per day of noncompliance up to one hundred thousand dollars ($100,000).(C) If the commissioner finds that a healthcare insurer or utilization review entity has complied with this subchapter, then the commissioner and the department shall provide notice to:(i) The healthcare insurer or utilization review entity; and(ii) The requesting healthcare provider.
(1) For any provision of this subchapter not subject to subsection (a) of this section, if a healthcare insurer or utilization review entity fails to comply with this subchapter, a healthcare provider may provide notice to the healthcare insurer or utilization review entity of the failure to comply.
(2) Within (1) business day after a healthcare provider provides notice that the healthcare insurer or utilization review entity has failed to comply with this subchapter, the healthcare insurer or utilization review entity shall:(A) Take action to address the failure retrospectively and prospectively to ensure compliance; or(B) (i) Refer the matter to the department for review.(ii) If the matter is referred to the department under subdivision (c)(2)(B)(i) of this section or by a complaint filed by a healthcare provider or a subscriber, the commissioner may conduct an investigation and hold a hearing under § 23-66-209 to determine whether or not the healthcare insurer or utilization review entity failed to comply with this subchapter with such frequency as to indicate a general business practice.(iii) If the commissioner finds that the healthcare insurer or utilization review entity failed to comply with this subchapter with such frequency as to indicate a general business practice, then the commissioner shall order the healthcare insurer or utilization review entity to: (a) Take action to address the failure retrospectively and prospectively to ensure compliance; and (b) Pay a civil fine not to exceed five thousand dollars ($5,000) per day of noncompliance up to one hundred thousand dollars ($100,000).(C) If the commissioner finds that a healthcare insurer or utilization review entity has complied with this subchapter, then the commissioner and the department shall provide notice to:(i) The healthcare insurer or utilization review entity; and(ii) The requesting healthcare provider.
(A) Take action to address the failure retrospectively and prospectively to ensure compliance; or
(B) (i) Refer the matter to the department for review.(ii) If the matter is referred to the department under subdivision (c)(2)(B)(i) of this section or by a complaint filed by a healthcare provider or a subscriber, the commissioner may conduct an investigation and hold a hearing under § 23-66-209 to determine whether or not the healthcare insurer or utilization review entity failed to comply with this subchapter with such frequency as to indicate a general business practice.(iii) If the commissioner finds that the healthcare insurer or utilization review entity failed to comply with this subchapter with such frequency as to indicate a general business practice, then the commissioner shall order the healthcare insurer or utilization review entity to: (a) Take action to address the failure retrospectively and prospectively to ensure compliance; and (b) Pay a civil fine not to exceed five thousand dollars ($5,000) per day of noncompliance up to one hundred thousand dollars ($100,000).
(i) Refer the matter to the department for review.
(ii) If the matter is referred to the department under subdivision (c)(2)(B)(i) of this section or by a complaint filed by a healthcare provider or a subscriber, the commissioner may conduct an investigation and hold a hearing under § 23-66-209 to determine whether or not the healthcare insurer or utilization review entity failed to comply with this subchapter with such frequency as to indicate a general business practice.
(iii) If the commissioner finds that the healthcare insurer or utilization review entity failed to comply with this subchapter with such frequency as to indicate a general business practice, then the commissioner shall order the healthcare insurer or utilization review entity to: (a) Take action to address the failure retrospectively and prospectively to ensure compliance; and (b) Pay a civil fine not to exceed five thousand dollars ($5,000) per day of noncompliance up to one hundred thousand dollars ($100,000).
(a) Take action to address the failure retrospectively and prospectively to ensure compliance; and
(b) Pay a civil fine not to exceed five thousand dollars ($5,000) per day of noncompliance up to one hundred thousand dollars ($100,000).
(C) If the commissioner finds that a healthcare insurer or utilization review entity has complied with this subchapter, then the commissioner and the department shall provide notice to:(i) The healthcare insurer or utilization review entity; and(ii) The requesting healthcare provider.
(i) The healthcare insurer or utilization review entity; and
(ii) The requesting healthcare provider.
(d) This section does not prohibit a healthcare provider or subscriber from filing a complaint with the department based on a violation of this subchapter.
(e) A fine imposed and collected under this section shall be deposited as special revenues into the State Treasury and credited to the Prior Authorization Transparency Act Fund.
(f) A healthcare insurer or utilization review entity does not violate this subchapter if:(1) Upon request, a healthcare insurer or a pharmacy benefits manager shall send additional information from the healthcare provider in compliance with this subchapter; and(2) The healthcare provider fails to send the requested information to the healthcare insurer or utilization review entity.
(1) Upon request, a healthcare insurer or a pharmacy benefits manager shall send additional information from the healthcare provider in compliance with this subchapter; and
(2) The healthcare provider fails to send the requested information to the healthcare insurer or utilization review entity.
(g) If the commissioner imposes a fine under this subchapter, the commissioner shall not impose an additional fine for the same underlying act or omission under any other provision of state law.