SB 475

Generally, this bill requires and prohibits certain actions related to prior

authorization of physical therapy, occupational therapy, speech therapy, chiropractic

services, and other health care services by certain health plans. Under the bill, every

health plan, when requested to reauthorize coverage, must issue a decision on

reauthorization of coverage of a service for which prior authorization was previously

obtained within 48 hours or prior authorization is assumed to be granted. Health

plans are prohibited under the bill from requiring prior authorization for the first 12

physical therapy, occupational therapy, speech therapy, or chiropractic visits with no

duration of care limitation or for any nonpharmacologic management of pain

provided to individuals with chronic pain for the first 90 days of treatment. The bill

requires plans to reference the applicable policy and include an explanation to the

service provider and to the covered individual for any denial of coverage for or

reduction in covered services. Further, the bill requires plans to compensate

providers of physical therapy services, occupational therapy services, speech

therapy services, or chiropractic services as specified under the bill for data entry of

clinical information that is required by a utilization review organization or

utilization management organization acting on behalf of a plan. A plan must also

impose copayment and coinsurance amounts on covered individuals for provided

services that are equivalent to copayment and coinsurance amounts imposed for

primary care services under the plan.

The bill also requires every utilization review organization and utilization

management organization that is providing review or management on behalf of a

health plan to provide to any licensed health care provider, upon request, all medical

evidence-based policy information that accompanies the algorithms that are used

to manage coverage and to operate and staff peer review activities with

Wisconsin-licensed health care providers holding credentials for the type of service

that is the subject of the review. The bill prohibits utilization review organizations

and utilization management organizations from using claims data as evidence of

outcomes for purposes of developing an algorithm to manage coverage or an approval

policy for coverage. Health plans to which the above requirements and prohibitions

apply are private health benefit plans and self-insured governmental health plans.

Additionally, the bill prohibits health care plans and self-insured

governmental health plans from requiring prior authorization for coverage of any

covered health care service that is incidental to a covered surgical service and

determined by the covered person's physician or other health care provider to be

medically necessary and of any covered urgent health care service as defined in the

bill. Current law prohibits health care plans and self-insured governmental health

plans from requiring prior authorization for coverage of emergency medical services.

This proposal may contain a health insurance mandate requiring a social and

financial impact report under s. 601.423, stats.