(a) Except as provided under subsection (c) of this section or § 23-99-1125, a healthcare insurer that uses a prior authorization process for healthcare services shall not require a healthcare provider to obtain prior authorization for a particular healthcare service that a healthcare provider has previously been subject to a prior authorization requirement if, in the most recent six-month evaluation period as described under subsection (b) of this section, the healthcare insurer has approved or would have approved no less than ninety percent (90%) of the prior authorization requests submitted by the healthcare provider for that particular healthcare service.
(b) (1) Except as provided under subsection (c) of this section, a healthcare insurer shall evaluate whether or not a healthcare provider qualifies for an exemption from prior authorization requirements under subsection (a) of this section one (1) time every twelve (12) months.(2) The six-month period for the evaluation period described under subsection (a) of this section shall be:(A) For a healthcare provider with an existing exemption under this section, any consecutive six-month period during the twelve (12) months following the effective date of the exemption;(B) For an initial healthcare provider, any consecutive six-month period during the twelve (12) months following the healthcare provider's first filed claim with the healthcare insurer;(C) For an initial healthcare insurer, any consecutive six-month period during the twelve (12) months following the healthcare insurer's commencement of operations subject to this subchapter; or(D) (i) For a healthcare provider denied an exemption under this section, any consecutive six-month period during the twelve (12) months before the healthcare provider's request for a new evaluation.(ii) A healthcare provider may request that the healthcare insurer perform a new evaluation twelve (12) months after the most recent denial.(3) The healthcare insurer shall choose a six-month evaluation period that allows time for:(A) The evaluation under subsection (a) of this section;(B) Notice to the healthcare provider of the decision; and(C) Appeal of the decision for an independent review to be completed by the end of the twelve-month period.
(1) Except as provided under subsection (c) of this section, a healthcare insurer shall evaluate whether or not a healthcare provider qualifies for an exemption from prior authorization requirements under subsection (a) of this section one (1) time every twelve (12) months.
(2) The six-month period for the evaluation period described under subsection (a) of this section shall be:(A) For a healthcare provider with an existing exemption under this section, any consecutive six-month period during the twelve (12) months following the effective date of the exemption;(B) For an initial healthcare provider, any consecutive six-month period during the twelve (12) months following the healthcare provider's first filed claim with the healthcare insurer;(C) For an initial healthcare insurer, any consecutive six-month period during the twelve (12) months following the healthcare insurer's commencement of operations subject to this subchapter; or(D) (i) For a healthcare provider denied an exemption under this section, any consecutive six-month period during the twelve (12) months before the healthcare provider's request for a new evaluation.(ii) A healthcare provider may request that the healthcare insurer perform a new evaluation twelve (12) months after the most recent denial.
(A) For a healthcare provider with an existing exemption under this section, any consecutive six-month period during the twelve (12) months following the effective date of the exemption;
(B) For an initial healthcare provider, any consecutive six-month period during the twelve (12) months following the healthcare provider's first filed claim with the healthcare insurer;
(C) For an initial healthcare insurer, any consecutive six-month period during the twelve (12) months following the healthcare insurer's commencement of operations subject to this subchapter; or
(D) (i) For a healthcare provider denied an exemption under this section, any consecutive six-month period during the twelve (12) months before the healthcare provider's request for a new evaluation.(ii) A healthcare provider may request that the healthcare insurer perform a new evaluation twelve (12) months after the most recent denial.
(i) For a healthcare provider denied an exemption under this section, any consecutive six-month period during the twelve (12) months before the healthcare provider's request for a new evaluation.
(ii) A healthcare provider may request that the healthcare insurer perform a new evaluation twelve (12) months after the most recent denial.
(3) The healthcare insurer shall choose a six-month evaluation period that allows time for:(A) The evaluation under subsection (a) of this section;(B) Notice to the healthcare provider of the decision; and(C) Appeal of the decision for an independent review to be completed by the end of the twelve-month period.
(A) The evaluation under subsection (a) of this section;
(B) Notice to the healthcare provider of the decision; and
(C) Appeal of the decision for an independent review to be completed by the end of the twelve-month period.
(c) A healthcare insurer may continue an exemption under subsection (a) of this section without evaluating whether or not the healthcare provider qualifies for the exemption under subsection (a) of this section for a particular evaluation period.
(d) A healthcare provider is not required to request an exemption under subsection (a) of this section to qualify for the exemption.
(e) (1) A healthcare insurer shall extend an exemption under subsection (a) of this section to a group of healthcare providers under the same tax identification number if either the healthcare insurer or the healthcare provider elects to do so, and:(A) A healthcare provider with an ownership interest in the entity to which the tax identification number is assigned does not object; or(B) The tax identification number is associated with a hospital licensed in this state and the chief executive officer of the hospital agrees to the exemption.(2) If a healthcare insurer elects to extend an exemption under subdivision (e)(1) of this section to a group of healthcare providers, the healthcare insurer shall provide to each affected healthcare provider at least sixty (60) days' prior notice of the election and of any modification to or termination of the election.(3) If, in the most recent six-month evaluation period, the healthcare insurer approved or would have approved less than eighty percent (80%) of the prior authorization requests submitted by a healthcare provider for a particular healthcare service, the healthcare provider shall not be eligible for inclusion under an exemption extended to healthcare providers under the same tax identification number under this subsection.
(1) A healthcare insurer shall extend an exemption under subsection (a) of this section to a group of healthcare providers under the same tax identification number if either the healthcare insurer or the healthcare provider elects to do so, and:(A) A healthcare provider with an ownership interest in the entity to which the tax identification number is assigned does not object; or(B) The tax identification number is associated with a hospital licensed in this state and the chief executive officer of the hospital agrees to the exemption.
(A) A healthcare provider with an ownership interest in the entity to which the tax identification number is assigned does not object; or
(B) The tax identification number is associated with a hospital licensed in this state and the chief executive officer of the hospital agrees to the exemption.
(2) If a healthcare insurer elects to extend an exemption under subdivision (e)(1) of this section to a group of healthcare providers, the healthcare insurer shall provide to each affected healthcare provider at least sixty (60) days' prior notice of the election and of any modification to or termination of the election.
(3) If, in the most recent six-month evaluation period, the healthcare insurer approved or would have approved less than eighty percent (80%) of the prior authorization requests submitted by a healthcare provider for a particular healthcare service, the healthcare provider shall not be eligible for inclusion under an exemption extended to healthcare providers under the same tax identification number under this subsection.