Prior authorization transparency, exemptions from prior authorization requirements, and granting rule-making authority. (FE)

The bill also requires that clinical review criteria that a health care plan uses for prior authorization decisions meet certain conditions, including be based on nationally recognized, generally accepted standards, be developed in accordance with the current standards of a national medical accreditation entity, and ensure quality of care and access to needed health care services.

Further, the bill prohibits a health care plan from denying a claim for failure to obtain prior authorization if the prior authorization requirement was not in effect on the date that the service was provided. The bill also prohibits plans and contracted utilization review organizations from deeming supplies or services as incidental and from denying a claim for supplies or services if a provided health care service associated with the supplies or services receives, or does not require, prior authorization.

Finally, the bill allows the commissioner of insurance to establish, by rule, that a health insurance policy or self-insured health plan must exempt health care providers from obtaining prior authorization for a health care item or service for a period of time determined by the commissioner if, in the most recent evaluation period determined by the commissioner, the policy or plan has approved or would have approved not less than a specified proportion of prior authorization requests submitted by the provider for the item or service. Under the bill, the commissioner may specify the health care items or services subject to the exemption and how providers can obtain an exemption, including a process for automatic evaluation.

This proposal may contain a health insurance mandate requiring a social and financial impact report under s. 601.423, stats.