(1) All health benefit plans and any third-party contractor or agent of such entities shall provide coverage for biomarker testing for the purposes of diagnosis, treatment, appropriate management, or ongoing monitoring of an enrollee’s disease or condition when use of the test is supported by medical and scientific evidence, including, but not limited to, any one of the following:(a) Labeled indications for an FDA-approved or -cleared test;(b) Indicated tests for an FDA-approved drug;(c) Warnings and precautions on FDA-approved drug labels;(d) Centers for Medicare and Medicaid Services (CMS) National Coverage Determinations or any Medicare Administrative Contractor (MAC) Local Coverage Determinations and associated Local Coverage Articles, regardless of jurisdiction; or(e) Testing recommendations or considerations from a:(i) Nationally recognized clinical practice guideline; or(ii) Consensus statement.
(a) Labeled indications for an FDA-approved or -cleared test;
(b) Indicated tests for an FDA-approved drug;
(c) Warnings and precautions on FDA-approved drug labels;
(d) Centers for Medicare and Medicaid Services (CMS) National Coverage Determinations or any Medicare Administrative Contractor (MAC) Local Coverage Determinations and associated Local Coverage Articles, regardless of jurisdiction; or
(e) Testing recommendations or considerations from a:(i) Nationally recognized clinical practice guideline; or(ii) Consensus statement.
(i) Nationally recognized clinical practice guideline; or
(ii) Consensus statement.
(2) All health benefit plans shall ensure that coverage as required in subsection (1) of this section is provided in a manner that limits disruptions in care including the need for multiple biopsies or biospecimen samples.
(3) Health benefit plans and health insurance issuers subject to this section shall update and make publicly available medical policies and coverage guidelines within sixty (60) days after enactment. Any updates or changes to medical policies impacting coverage of biomarker testing must be made publicly available thirty (30) days in advance of the effective date of the updated policy.
(4) If a health benefit plan or health insurance issuer denies a claim for coverage of testing that is supported by any evidence in subsection (1) of this section, the health benefit plan or health insurance issuer shall provide to the requesting entity, whether it is the provider, individual or laboratory, specific written justification explaining in detail why the claim for coverage was denied as it pertains to the individual for whom the test was ordered.
(5) If utilization review, including, but not limited to, prior authorization, is required, the health benefit plan, utilization review entity or any third party acting on behalf of an organization or entity subject to Section 83-9-603 and this section shall approve or deny a prior authorization request and notify the enrollee, the enrollee’s health care provider, and any entity requesting authorization of the service within the timeframe established in Section 83-5-913 for nonurgent requests and Section 83-5-915 for urgent requests.
(6) If prior authorization is required, requests for biomarker tests may be submitted by:(a) The ordering or treating provider;(b) The rendering laboratory provider; or(c) The enrollee or enrollee’s representative.
(a) The ordering or treating provider;
(b) The rendering laboratory provider; or
(c) The enrollee or enrollee’s representative.
(7) In addition to the provisions of Section 83-5-901 et seq., a patient and prescribing practitioner shall have access to a clear, readily accessible, and convenient process to request an exception to a coverage policy or an adverse utilization review determination of a health benefit plan or health insurance issuer. The process shall be made readily accessible on the health benefit plan’s or health insurance issuer’s website.
(8) The Department of Insurance may conduct periodic audits and reviews to ensure entity compliance with Section 83-9-603 and this section.
(9) Section 83-9-603 and this section shall apply to all health benefit plans, contracts or agreements that are entered into or renewed on or after July 1, 2026.