Prior authorization shall not be required unless the health carrier or utilization review entity makes a determination that less than 90% of prior authorization requests submitted by that health care provider in the previous evaluation period, as defined in the act, were or would have been approved. The act establishes separate 90% thresholds for requiring prior authorization for individual health care services or requiring prior authorization for all health care services.

The act specifies requirements for notifying the provider of determinations under the act, requires health carriers and utilization review entities to establish an appeals process for determinations under the act, and requires carriers and utilization review entities to maintain an online portal giving providers access to certain information.

Lastly, no health carrier or utilization review entity shall deny or reduce payments to a health care provider who had a prior authorization, unless the provider made a knowing and material misrepresentation with the intent to deceive the carrier or utilization review entity, or unless the health care service was not substantially performed.

This act shall not apply to Medicaid, except with regard to a Medicaid managed care organization as defined by law. The act also does not apply to providers who have not participated in a health benefit plan offered by the carrier for at least one full evaluation period. This act shall not be construed to authorize providers to provide services outside the scope of their licenses, nor to require health carriers or utilization review entities to pay for care provided outside the scope of a provider's license.

This act is similar to SB 983 (2024) and SB 576 (2023), and identical to HB 1045 (2023).

ERIC VANDER WEERD