Title 26.1 — Insurance

The commissioner may adopt rules for the implementation and administration of this chapter.

A person doing business in this state as a discount plan organization on or before the effective date of this chapter has six months following the effective date of this Act to come into compliance with the requirements of this chapter.

For the purposes of this chapter, unless the context otherwise requires: 1. a. "Comprehensive medication management" means medication management pursuant to a standard of care that ensures each enrollee's medications, both prescription and nonprescription, are individually assess…

1. The commissioner shall establish and facilitate an advisory committee to implement the provisions of this chapter. The advisory committee shall develop best practice recommendations for the implementation of comprehensive medication management and on standards to ensure pharma…

The commissioner may adopt reasonable rules for the implementation and administration of the provisions of this chapter.

As used in this chapter: 1. "Adverse determination" means a decision by a prior authorization review organization relating to an admission, extension of stay, or health care service that is partially or wholly adverse to the enrollee, including a decision to deny an admission, ex…

1. A prior authorization review organization shall make any prior authorization requirements and restrictions readily accessible on the organization's website to enrollees, health care professionals, and the general public. Requirements include the written clinical criteria and b…

A prior authorization review organization shall ensure all adverse determinations are made by a licensed physician or licensed pharmacist. The reviewing individual: 1. Must have experience treating patients with the condition or illness for which the health care service is being …

1. A prior authorization review organization shall ensure all appeals are reviewed by a physician. The reviewing individual: a. Shall possess a valid nonrestricted license to practice medicine. b. Must be in active practice in the same or similar specialty as the physician who ty…

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…