Title 26, Title 26 — Insurance Code

Contents of corporate governance annual disclosure. (a) An insurer or insurance group shall have discretion over the manner in which a CGAD is submitted, provided the CGAD shall contain the material information necessary to permit the commissioner to gain an understanding of the …

Confidentiality. (a) Documents, materials or other information, including the CGAD, in the possession or control of the department that are obtained by, created by or disclosed to the commissioner or any other person under this act, are recognized by this state as being proprieta…

NAIC and third party consultants. (a) The commissioner may retain, at the insurer's expense, third party consultants, including attorneys, actuaries, accountants and other experts not otherwise a part of the commissioner's staff, as may be reasonably necessary to assist the commi…

Sanctions. Any insurer failing, without just cause, to timely file the CGAD required by this act shall be required, after notice and hearing, to pay a penalty of one hundred dollars ($100.00) for each day that the CGAD is not filed, to be recovered by the commissioner. The maximu…

Short title. This act shall be known and may be cited as the "Ensuring Transparency in Prior Authorization Act."

Definitions. (a) As used in this act: (i) "Adverse determination" means a decision by a health insurer or contracted utilization review entity to deny, reduce or terminate benefit coverage for health care services furnished or proposed to be furnished because the services are not…

Disclosure and review of prior authorization requirements. (a) Each health insurer or contracted utilization review entity shall make any current prior authorization requirements and restrictions easily accessible on its website to enrollees, health care providers and the general…

Persons qualified to make adverse determinations. (a) Each health insurer or contracted utilization review entity shall ensure that all adverse determinations are made by a physician or other appropriate licensed health care provider who has: (i) Sufficient medical knowledge in a…

Consultation after issuing an adverse determination. After issuing an adverse determination, the health insurer or contracted utilization review entity shall provide the opportunity to the health care provider to discuss the medical necessity of the health care service with the p…

Requirements applicable to persons reviewing appeals. (a) Each health insurer or contracted utilization review entity shall ensure that all appeals of adverse determinations are reviewed by a physician or other appropriate licensed health care provider who has: (i) Sufficient med…

Health insurer or contracted utilization review entities' obligations regarding prior authorization for nonurgent health care services If a health insurer or contracted utilization review entity requires prior authorization of a health care service, the health insurer or contract…

Health insurer or contracted utilization review entities' obligations with respect to prior authorizations for urgent health care services. Each health insurer or contracted utilization review entity shall make an authorization or adverse determination concerning urgent health ca…

No prior authorization for medications for opioid use disorder. No health insurer or contracted utilization review entity shall require prior authorization for the provision of medications for opioid use disorder.

Length of authorization generally; revocation of prior authorizations prohibited; length of authorization for chronic or long-term care conditions. (a) Each authorization shall have the following timelines: (i) Outpatient service prior authorizations shall be valid for a period o…

Continuity of care for enrollees. (a) On receipt of all necessary information documenting an authorization from the enrollee, previous health insurer or the enrollee's health care provider, a health insurer or contracted utilization review entity shall honor an authorization gran…

Provider exemptions from prior authorization requirements. (a) A health care provider, as identified by a unique national provider identifier, shall be granted a twelve (12) month or one (1) year exemption from completing a prior authorization request for a health care service, e…

Prior authorization for rehabilitative or habilitative services. (a) A health insurer or contracted utilization review entity shall not require prior authorization for rehabilitative or habilitative services including, but not limited to, physical therapy services or occupational…

Definitions. (a) As used in this chapter: (i) "Applicant" means a health care provider who submits an application to a health carrier to become credentialed as a participating health care provider in one (1) or more of the health carrier's provider networks; (ii) "Application" me…

Health care provider credentialing; requirements. (a) Within seven (7) calendar days after a health carrier receives an application for credentialing, the health carrier shall provide the applicant notice of receipt of the application in written or electronic form and contact inf…