(a) A health carrier shall maintain a complete list of healthcare services for which a prior authorization is required.
(b) The clinical review criteria for healthcare services or prescription drugs requiring prior authorization must:(1) Be based on nationally recognized, generally accepted standards for national, clinical criteria, except where state law provides its own standard;(2) Not be arbitrary and must be cited by the utilization review organization;(3) Be developed in accordance with the current standards of a national medical accreditation entity;(4) Ensure quality of care and access to needed healthcare services;(5) Be evidence-based;(6) Be sufficiently flexible to allow deviations from norms when justified on a case-by-case basis; and(7) Be evaluated and updated in accordance with § 56-7-3718.
(1) Be based on nationally recognized, generally accepted standards for national, clinical criteria, except where state law provides its own standard;
(2) Not be arbitrary and must be cited by the utilization review organization;
(3) Be developed in accordance with the current standards of a national medical accreditation entity;
(4) Ensure quality of care and access to needed healthcare services;
(5) Be evidence-based;
(6) Be sufficiently flexible to allow deviations from norms when justified on a case-by-case basis; and
(7) Be evaluated and updated in accordance with § 56-7-3718.
(c) A claim for failure to obtain prior authorization must not be denied if the prior authorization requirement was not in effect on the date of service on the claim.