HB 1271

Bill Subjects

Health, Health Care Professionals Insurance Generally

Abstract

Provides that when a health plan makes an adverse determination in response to a health care provider's request for prior authorization of a health care service: (1) the health plan is required to provide the health care provider with an opportunity to have a peer to peer conversation with a clinical peer concerning the adverse determination; and (2) the peer to peer conversation opportunity must be provided not more than seven business days after the health plan receives the health care provider's request for the peer to peer conversation. Provides that after December 31, 2023: (1) if a health plan, during a six month evaluation period, approves at least 90% of a health care provider's requests for prior authorization for a particular type of health care service, the health plan may not require the health care provider to obtain prior authorization for that type of health care service for the entire duration of an exemption period of six calendar months immediately following the evaluation period; and (2) at the conclusion of the initial exemption period, the health plan shall continue a health care provider's exemption for consecutive periods of six months unless the health plan rescinds the health care provider's exemption; (3) a health plan's rescission of a health care provider's exemption must be based on: (A) a determination by a physician that, in cases randomly selected for review, less than 90% of the health care services provided by the health care provider met the health plan's medical necessity criteria; or (B) the health care provider committing health care provider fraud or the health care provider's license or legal authorization to provide health care services being suspended or revoked; (4) a health care provider whose exemption is rescinded may initiate a review of the rescission by an independent review panel; (5) the independent review panel is required to determine: (A) whether at least 90% of the health care services provided by the health care provider met the health plan's medical necessity criteria; or (B) whether the health care provider committed health care provider fraud or the health care provider's license or legal authorization to provide health care services is suspended or revoked; (6) the health plan is required to restore the health care provider's exemption if the independent review panel's determination is in favor of the health care provider; and (7) if a health care provider whose exemption is rescinded does not initiate a review or if the independent review panel's determination is not in favor of the health care provider, the health plan is not required to determine again whether the health care provider is entitled to an exemption until the first evaluation period beginning at least two years later. Requires the insurance commissioner to adopt rules.