Title 26.1, Insurance

1. If a prior authorization review organization requires prior authorization of a health care service, the prior authorization review organization shall make a prior authorization or adverse determination and notify the enrollee and the enrollee's health care provider of the deci…

A prior authorization review organization shall render a prior authorization or adverse determination concerning urgent health care services and notify the enrollee and the enrollee's health care provider of that prior authorization or adverse determination within seventy-two hou…

1. A prior authorization review organization may not require prior authorization for prehospital transportation or for the provision of emergency health care services for an emergency medical condition. 2. A prior authorization review organization shall allow an enrollee and the …

A prior authorization review organization may not require prior authorization for the provision of medication-assisted treatment for the treatment of opioid use disorder.

A prior authorization review organization may not revoke, limit, condition, or restrict a prior authorization if care is provided within forty-five business days from the date the health care provider received the prior authorization unless there is evidence the prior authorizati…

A prior authorization is valid for at least six months after the date the health care provider receives the prior authorization.

If a prior authorization review organization requires a prior authorization for a health care service for the treatment of a chronic or long-term care condition, the prior authorization remains valid for twelve months.

1. On receipt of information documenting a prior authorization from the enrollee or from the enrollee's health care provider, a prior authorization review organization shall honor a prior authorization granted to an enrollee from a previous prior authorization review organization…

If a prior authorization review organization fails to comply with the deadlines and other requirements in this chapter, any health care services subject to review automatically are deemed authorized by the prior authorization review organization.

1. A prior authorization review organization shall have written procedures for appeals of adverse determinations. The right to appeal must be available to the enrollee and the attending health care professional. 2. The enrollee may review the information relied on in the course o…

1. If, during a plan year, a prior authorization review organization changes coverage terms for a health care service or the clinical criteria used to conduct prior authorizations for a health care service, the change in coverage terms or in clinical criteria does not apply until…

If the prior authorization review organization and the claims administrator are separate entities, the prior authorization review organization shall notify, either electronically or in writing, the appropriate claims administrator for the health benefit plan of any adverse determ…

1. A prior authorization review organization shall report to the insurance commissioner by September first of each year information regarding prior authorization requests for the previous calendar year. 2. The report must be available online and in a form specified by the commiss…