Prior Authorization Exemption Health-care Provider

With regard to health-care services, section 1 of starting January 1, 2024, the bill requires a health insurance carrier (carrier) or private utilization review organization (organization) , as applicable, to offer a qualified provider with at least a 95% approval rate of prior authorization requests over the prior 12 months an alternative to prior authorization requirements, including an exemption from the requirements or incentive awards or other innovative programs to reward provider compliance designed by the carrier or organization that reduce patient wait times or administrative burdens to receiving the requested health-care service . To be a "qualified provider", a provider must:

• Be, and have been continuously for at least the immediately preceding 12 months, a participating provider; and
• Have, over the immediately preceding 12 months: At least a 95% approval rate on prior authorization requests submitted for the same health-care service; and submitted at least 24 prior authorization requests for the same health-care service.

A carrier or organization is required to inform a provider of the provider's status as a qualified provider and, at least annually, to reevaluate whether a provider satisfies the requirements of a qualified provider. With regard to drug benefits, section 2 requires a carrier or pharmacy benefit management firm, as applicable, to offer the same types of alternatives to prior authorization requirements to a provider who has at least a 95% approval rate of prior authorization requests over the prior 12 months.

(Note: Italicized words indicate new material added to the original summary; dashes through words indicate deletions from the original summary.)

(Note: This summary applies to the reengrossed version of this bill as introduced in the second house.)