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LEGISLATURE
OF
THE
STATE
OF
IDAHO
Sixty-eighth
Legislature
Second
Regular
Session
-
2026
IN
THE
HOUSE
OF
REPRESENTATIVES
HOUSE
BILL
NO.
611
BY
HEALTH
AND
WELFARE
COMMITTEE
AN
ACT
1
RELATING
TO
HEALTH
INSURANCE;
AMENDING
TITLE
41,
IDAHO
CODE,
BY
THE
ADDITION
2
OF
A
NEW
CHAPTER
35,
TITLE
41,
IDAHO
CODE,
TO
ESTABLISH
THE
IDAHO
PRIOR
3
AUTHORIZATION
REFORM
ACT,
TO
PROVIDE
A
SHORT
TITLE,
TO
PROVIDE
THE
PUR
-
4
POSE
OF
THE
CHAPTER,
TO
DEFINE
TERMS,
TO
PROVIDE
FOR
DISCLOSURE
AND
RE
-
5
VIEW
OF
PRIOR
AUTHORIZATION
REQUIREMENTS,
TO
PROVIDE
FOR
STANDARDIZED
6
ELECTRONIC
PRIOR
AUTHORIZATIONS,
TO
PROVIDE
FOR
STANDARD
PRIOR
AUTHO
-
7
RIZATIONS,
TO
PROVIDE
FOR
EXPEDITED
PRIOR
AUTHORIZATIONS,
TO
PROVIDE
8
FOR
NOTIFICATIONS
FOR
ADVERSE
DETERMINATIONS,
TO
PROVIDE
FOR
PERSON
-
9
NEL
QUALIFIED
TO
REVIEW
APPEALS,
TO
PROVIDE
FOR
INSURER
REVIEW
OF
PRIOR
10
AUTHORIZATION
REQUIREMENTS,
TO
PROVIDE
FOR
REVOCATION
OF
PRIOR
AUTHO
-
1
1
RIZATIONS,
TO
PROVIDE
FOR
THE
LENGTH
OF
APPROVALS,
TO
PROVIDE
FOR
AP
-
12
PROVALS
FOR
CHRONIC
CONDITIONS,
TO
PROVIDE
FOR
CONTINUITY
OF
PRIOR
AP
-
13
PROVALS,
TO
PROVIDE
FOR
THE
EFFECT
OF
AN
INSURER'S
FAILURE
TO
COMPLY,
14
TO
PROVIDE
FOR
ENFORCEMENT
AND
ADMINISTRATION,
TO
PROVIDE
FOR
REPORTS
15
TO
THE
DEPARTMENT
OF
INSURANCE,
TO
PROVIDE
FOR
FALSE
REQUESTS
FOR
PRIOR
16
AUTHORIZATION,
AND
TO
PROVIDE
RULEMAKING
AUTHORITY;
AND
DECLARING
AN
17
EMERGENCY
AND
PROVIDING
AN
EFFECTIVE
DATE.
18
Be
It
Enacted
by
the
Legislature
of
the
State
of
Idaho:
19
SECTION
1.
That
Title
41,
Idaho
Code,
be,
and
the
same
is
hereby
amended
20
by
the
addition
thereto
of
a
NEW
CHAPTER
,
to
be
known
and
designated
as
Chap
-
21
ter
35,
Title
41,
Idaho
Code,
and
to
read
as
follows:
22
CHAPTER
35
23
IDAHO
PRIOR
AUTHORIZATION
REFORM
24
41
-
3501.
SHORT
TITLE.
This
chapter
shall
be
known
and
may
be
cited
as
25
the
"Idaho
Prior
Authorization
Reform
Act."
26
41
-
3502.
PURPOSE.
The
purpose
of
this
chapter
is
to:
27
(1)
Protect
the
health
care
provider
-
patient
relationship
from
unrea
-
28
sonable
third
-
party
interference;
29
(2)
Prevent
prior
authorization
programs
from
hindering
the
indepen
-
30
dent
medical
judgment
of
a
physician
or
other
health
care
provider;
and
31
(3)
Ensure
the
transparency
of
a
fair
and
consistent
process
for
health
32
care
providers
and
their
patients.
33
41
-
3503.
APPLICABILITY
AND
SCOPE.
This
chapter
applies
to
every
34
health
benefit
plan,
as
defined
in
section
41
-
5903,
Idaho
Code,
to
all
35
issuers
of
health
benefit
plans,
and
to
all
utilization
reviews
and
utiliza
-
36
tion
review
organizations,
as
defined
in
section
41
-
5903,
Idaho
Code,
except
37
for
employee
or
employer
self
-
insured
health
benefit
plans
under
the
fed
-
38
eral
employee
retirement
income
security
act
of
1974
or
health
care
provided
39
2
pursuant
to
worker's
compensation
law.
This
chapter
does
not
diminish
the
1
duties
and
responsibilities
under
other
federal
or
state
law
or
rules
pro
-
2
mulgated
under
those
laws
applicable
to
a
health
insurer,
health
insurance
3
issuer,
health
benefit
plan,
utilization
review
plan,
or
utilization
review
4
organization.
5
41
-
3504.
DEFINITIONS.
For
the
purposes
of
this
chapter:
6
(1)
"Adverse
determination"
means
a
determination
by
a
health
insur
-
7
ance
issuer
that,
based
on
the
information
provided,
a
pre
-
service
request
8
for
a
benefit
under
the
health
insurance
issuer's
health
benefit
plan
upon
9
application
of
any
utilization
review
technique
does
not
meet
the
health
10
insurance
issuer's
requirements
for
medical
necessity,
appropriateness,
1
1
health
care
setting,
level
of
care,
or
effectiveness
or
is
determined
to
be
12
experimental
or
investigational,
and
the
requested
benefit
is
therefore
13
denied.
14
(2)
"Appeal"
means
a
formal
request,
either
orally
or
in
writing,
to
re
-
15
consider
an
adverse
determination.
16
(3)
"Approval"
means
a
determination
by
a
health
insurance
issuer
that
17
a
health
care
service
has
been
reviewed
and,
based
on
the
information
pro
-
18
vided,
satisfies
the
health
insurance
issuer's
requirements
for
medical
ne
-
19
cessity
and
appropriateness.
20
(4)
"Clinical
review
criteria"
means
the
written
screening
procedures,
21
decision
abstracts,
clinical
protocols,
and
practice
guidelines
used
by
a
22
health
insurance
issuer
to
determine
the
necessity
and
appropriateness
of
23
health
care
services.
24
(5)
"Department"
means
the
Idaho
department
of
insurance.
25
(6)
"Emergency
medical
condition"
means
a
medical
condition
manifest
-
26
ing
itself
by
acute
symptoms
of
sufficient
severity,
including
but
not
lim
-
27
ited
to
severe
pain,
such
that
a
prudent
layperson
who
possesses
an
average
28
knowledge
of
health
and
medicine
could
reasonably
expect
the
absence
of
im
-
29
mediate
medical
attention
to
result
in:
30
(a)
Placing
the
health
of
the
individual
or,
with
respect
to
a
pregnant
31
woman,
the
health
of
the
woman
or
her
unborn
child,
in
serious
jeopardy;
32
(b)
Serious
impairment
to
bodily
functions;
or
33
(c)
Serious
dysfunction
of
any
bodily
organ
or
part.
34
(7)
"Emergency
services"
means
health
care
items
and
services
fur
-
35
nished
or
required
to
evaluate
and
treat
an
emergency
medical
condition.
36
(8)
"Enrollee"
means
any
person
and
the
person's
dependents
enrolled
in
37
or
covered
by
a
health
care
plan.
38
(9)(a)
"Expedited
prior
authorization
request"
means
a
pre
-
service
or
39
concurrent
care
claim
for
medical
care
or
treatment
for
which
applica
-
40
tion
of
the
time
periods
for
making
a
non
-
expedited
prior
authorization
41
could,
in
the
opinion
of
a
treating
health
care
professional
or
health
42
care
provider
with
knowledge
of
the
enrollee's
medical
condition:
43
(i)
Seriously
jeopardize
the
life
or
health
of
the
enrollee
or
the
44
ability
of
the
enrollee
to
regain
maximum
function;
45
(ii)
Subject
the
enrollee
to
severe
pain
that
cannot
be
adequately
46
managed
without
the
care
or
treatment
that
is
the
subject
of
the
47
authorization
request;
or
48
3
(iii)
Lead
to
likely
onset
of
an
emergency
medical
condition
if
the
1
service
is
not
rendered
during
the
time
period
to
render
a
prior
2
authorization
determination
for
an
urgent
medical
service.
3
(b)
"Expedited
prior
authorization
request"
does
not
apply
to
emer
-
4
gency
services.
5
(10)
"Health
care
professional"
means
a
physician,
a
registered
profes
-
6
sional
nurse,
or
another
individual
appropriately
licensed
or
registered
to
7
provide
health
care
services.
8
(11)
"Health
care
provider"
means
any
physician,
hospital,
ambulatory
9
surgery
center,
or
other
person
or
facility
that
is
licensed
or
otherwise
au
-
10
thorized
to
deliver
health
care
services.
1
1
(12)
"Health
care
service"
means
any
services
or
level
of
services
12
included
in
the
furnishing
of
medical
care
to
an
individual
or
the
hospital
-
13
ization
incident
to
the
furnishing
of
such
care,
as
well
as
the
furnishing
of
14
any
other
services
to
any
person
for
the
purpose
of
preventing,
alleviating,
15
curing,
or
healing
human
illness
or
injury,
including
behavioral
health,
16
mental
health,
home
health,
and
pharmaceutical
services,
products,
and
med
-
17
ications.
18
(13)
"Health
insurance
issuer"
means
the
issuer
of
a
health
benefit
19
plan.
20
(14)
"Medically
necessary"
means
care
that
a
health
care
professional
21
exercising
prudent
clinical
judgment
would
provide
to
a
patient
for
the
pur
-
22
pose
of
preventing,
diagnosing,
or
treating
an
illness,
injury,
disease,
or
23
its
symptoms
and
that
is:
24
(a)
In
accordance
with
generally
accepted
standards
of
medical
prac
-
25
tice;
26
(b)
Clinically
appropriate
in
terms
of
type,
frequency,
extent,
site,
27
and
duration
and
considered
effective
for
the
patient's
illness,
in
-
28
jury,
or
disease;
29
(c)
Focused
on
what
is
best
for
the
patient's
health
outcome;
and
30
(d)
Not
primarily
for
the
convenience
of
the
patient,
treating
physi
-
31
cian,
other
health
care
professional,
caregiver,
family
member,
or
32
other
interested
party.
33
(15)
"NCPDP
SCRIPT
standard"
means
the
national
council
for
prescrip
-
34
tion
drug
programs
SCRIPT
standard
version
2017071,
or
the
most
recent
stan
-
35
dard
adopted
by
the
United
States
department
of
health
and
human
services.
36
Subsequently
released
versions
of
the
NCPDP
SCRIPT
standard
may
be
used.
37
(16)
"Physician"
means
any
person
with
a
valid
doctor
of
medicine,
doc
-
38
tor
of
osteopathy,
or
doctor
of
podiatry
degree.
39
(17)
"Prior
authorization"
means
the
process
by
which
a
health
insur
-
40
ance
issuer
determines
the
medical
necessity
and
medical
appropriateness
of
41
an
otherwise
covered
health
care
service
before
the
rendering
of
such
health
42
care
service.
While
not
requiring
explicit
approval,
any
notification
re
-
43
quired
of
an
enrollee,
health
care
professional,
or
health
care
provider
by
44
the
health
insurance
issuer
before,
at
the
time
of,
or
concurrent
to
provid
-
45
ing
a
health
care
service
shall
be
included
within
the
definition
of
"prior
46
authorization."
47
(18)
"Utilization
review
organization"
has
the
meaning
given
to
that
48
term
in
section
41
-
5903,
Idaho
Code.
49
4
41
-
3505.
DISCLOSURE
AND
REVIEW
OF
PRIOR
AUTHORIZATION
REQUIRE
-
1
MENTS.
(1)
A
health
insurance
issuer
shall
maintain
a
complete
list
of
2
services
for
which
prior
authorization
is
required,
including
for
all
ser
-
3
vices
where
prior
authorization
is
performed
by
an
entity
under
contract
4
with
the
health
insurance
issuer.
5
(2)
A
health
insurance
issuer
shall
make
any
current
prior
authoriza
-
6
tion
requirements
and
restrictions,
including
the
written
clinical
review
7
criteria,
readily
accessible
and
conspicuously
posted
on
its
website
or
8
online
portal
to
enrollees,
health
care
professionals,
and
health
care
9
providers.
Content
published
by
a
third
party
and
licensed
for
use
by
a
10
health
insurance
issuer
may
be
made
available
through
the
health
insurance
1
1
issuer's
secure,
password
-
protected
website
or
online
portal
as
long
as
the
12
access
requirements
of
the
website
do
not
unreasonably
restrict
access.
13
Requirements
shall
be
described
in
detail,
written
in
easily
understandable
14
language,
and
readily
available
to
the
health
care
professional
and
health
15
care
provider
at
the
point
of
care.
The
website
or
online
portal
shall
indi
-
16
cate
for
each
service
subject
to
prior
authorization:
17
(a)
The
date
on
which
prior
authorization
became
required
for
policies
18
issued
or
health
benefit
plan
documents
delivered
in
Idaho,
including
19
the
effective
dates
and
the
termination
dates,
if
applicable,
in
Idaho;
20
(b)
The
date
on
which
the
Idaho
-
specific
requirement
was
listed
on
the
21
website
or
online
portal
of
the
health
insurance
issuer;
22
(c)
If
applicable,
the
date
on
which
prior
authorization
requirement
23
was
removed
for
Idaho;
and
24
(d)
If
applicable,
access
to
a
standardized
electronic
prior
autho
-
25
rization
request
transaction
process.
26
(3)
The
clinical
review
criteria
must:
27
(a)
Be
consistent
with
nationally
accepted
standards
generally
recog
-
28
nized
by
physicians
and
health
care
providers
practicing
in
relevant
29
medical
and
clinical
specialties
except
where
state
law
provides
its
30
own
standard;
31
(b)
Be
developed
in
accordance
with
the
current
standards
of
a
national
32
medical
accreditation
entity;
33
(c)
Ensure
quality
of
care
and
access
to
needed
health
care
services;
34
(d)
Be
evidence
-
based
on
sources,
including
peer
-
reviewed
scientific
35
studies;
36
(e)
Be
sufficiently
flexible
to
allow
deviations
from
norms
when
justi
-
37
fied
on
a
case
-
by
-
case
basis;
and
38
(f)
Be
evaluated
and
updated
under
the
direction
of
a
physician
li
-
39
censed
in
the
relevant
specialty
at
least
annually.
40
(4)
A
health
insurance
issuer
shall
not
deny
a
claim
for
failure
to
ob
-
41
tain
prior
authorization
if
the
prior
authorization
requirement
was
not
in
42
effect
on
the
date
of
service
or
if
the
claim
or
prior
authorization
require
-
43
ments
were
not
publicly
disclosed
by
the
plan
on
the
health
insurance
is
-
44
suer's
website,
online
portal,
or
other
materials.
45
(5)
A
health
insurance
issuer
shall
not
deem
as
incidental
or
deny
sup
-
46
plies
or
health
care
services
that
are
routinely
used
as
part
of
a
health
care
47
service
when:
48
(a)
An
associated
health
care
service
has
received
prior
authoriza
-
49
tion;
or
50
5
(b)
Prior
authorization
for
the
health
care
service
is
not
required.
1
(6)
If
a
health
insurance
issuer
intends
either
to
implement
a
new
prior
2
authorization
requirement
or
restriction
or
to
amend
an
existing
require
-
3
ment
or
restriction,
the
health
insurance
issuer
shall
provide
impacted
4
enrollees,
contracted
health
care
professionals,
and
contracted
health
care
5
providers
of
enrollees
written
notice
of
the
new
or
amended
requirement
no
6
less
than
sixty
(60)
days
before
the
requirement
or
restriction
is
imple
-
7
mented.
Written
notice
may
take
the
form
of
a
conspicuous
notice
posted
on
8
the
health
insurance
issuer's
public
website
or
online
portal
for
contracted
9
health
care
professionals
and
contracted
health
care
providers
or
email
no
-
10
tice
to
health
care
professionals
or
providers.
A
health
insurance
issuer
1
1
shall
provide
email
notices
to
all
impacted
enrollees
and
to
health
care
12
professionals
or
health
care
providers
if
the
health
care
professional
or
13
health
care
provider
has
requested
to
receive
the
notice
through
email.
A
14
new
or
amended
requirement
shall
not
be
implemented
unless
the
health
insur
-
15
ance
issuer's
website
or
online
portal
has
been
updated
to
reflect
the
new
16
or
amended
requirement
or
restriction.
Written
notice
of
a
new,
amended,
or
17
restricted
prior
authorization
requirement
may
be
provided
less
than
sixty
18
(60)
days
in
advance
of
implementation
if
a
health
insurance
issuer
deter
-
19
mines
and
contemporaneously
notifies
the
department
in
writing
that:
20
(a)
The
health
insurance
issuer
has
identified
fraudulent
or
abusive
21
practices
related
to
the
health
care
service;
22
(b)
The
health
care
service
is
unavailable
or
scarce,
necessitating
the
23
use
of
an
alternative
health
care
service;
24
(c)
The
health
care
service
is
newly
introduced
to
the
health
care
mar
-
25
ket
and
a
delay
in
providing
coverage
for
the
health
care
service
would
26
not
be
in
the
best
interests
of
enrollees;
27
(d)
The
health
care
service
is
the
subject
of
a
clinical
trial
autho
-
28
rized
by
the
United
States
food
and
drug
administration;
29
(e)
Changes
to
the
health
care
service
or
its
availability
are
other
-
30
wise
required
by
law
to
be
made
by
the
health
insurance
issuer
in
less
31
than
sixty
(60)
days;
or
32
(f)
The
prior
authorization
requirement
is
being
removed.
33
(7)
Health
insurance
issuers
using
prior
authorization
shall
make
sta
-
34
tistics
available
regarding
prior
authorization
approvals
and
denials
on
35
their
website
or
online
portal
in
a
readily
accessible
format.
Following
36
each
calendar
year,
the
statistics
shall
be
updated
annually
by
February
1,
37
and
include
all
of
the
following
information:
38
(a)
A
list
of
all
health
care
services,
including
medications,
that
are
39
subject
to
prior
authorization;
40
(b)
The
percentage
of
standard
prior
authorization
requests
that
were
41
approved,
aggregated
for
all
items
and
services;
42
(c)
The
percentage
of
standard
prior
authorization
requests
that
were
43
denied,
aggregated
for
all
items
and
services;
44
(d)
The
percentage
of
prior
authorization
requests
that
were
approved
45
after
appeal,
aggregated
for
all
items
and
services;
46
(e)
The
percentage
of
prior
authorization
requests
for
which
the
time
47
frame
for
review
was
extended,
and
the
request
was
approved
,
aggregated
48
for
all
items
and
services;
49
6
(f)
The
percentage
of
expedited
prior
authorization
requests
that
were
1
approved,
aggregated
for
all
items
and
services;
2
(g)
The
percentage
of
expedited
prior
authorization
requests
that
were
3
denied,
aggregated
for
all
items
and
services;
4
(h)
The
average
and
median
time
that
elapsed
between
the
submission
of
a
5
request
and
a
determination
by
the
health
insurance
issuer
for
standard
6
prior
authorization,
aggregated
for
all
items
and
services;
and
7
(i)
The
average
and
median
time
that
elapsed
between
the
submission
of
8
a
request
and
a
determination
by
the
health
insurance
issuer
for
expe
-
9
dited
prior
authorization,
aggregated
for
all
items
and
services.
10
41
-
3506.
STANDARDIZED
ELECTRONIC
PRIOR
AUTHORIZATIONS.
(1)
If
a
1
1
health
insurance
issuer
requires
prior
authorization
of
a
health
care
ser
-
12
vice,
the
issuer
or
its
contracted
utilization
review
organization
shall,
13
by
July
1,
2026,
make
available
a
standardized
electronic
prior
authoriza
-
14
tion
request
transaction
process
using
an
internet
website,
online
portal,
15
or
similar
electronic,
web
-
based
system.
After
January
1,
2027,
a
health
16
insurance
issuer
shall
accept
and
respond
to
prior
authorization
requests
17
under
the
pharmacy
benefit
through
a
secure
electronic
transmission
using
18
the
NCPDP
SCRIPT
standard
electronic
prior
authorization
transactions.
19
(2)
No
later
than
January
1,
2027,
all
health
care
professionals
and
20
health
care
providers
shall
be
required
to
use
the
standardized
electronic
21
prior
authorization
request
transaction
process
made
available
as
required
22
by
subsection
(1)
of
this
section.
23
(3)
For
purposes
of
this
chapter,
a
prior
authorization
request
shall
24
be
considered
received
upon:
25
(a)
Confirmation
of
electronic
submission;
or
26
(b)
The
next
calendar
day
following
submission
if
submitted
outside
of
27
normal
business
hours.
28
41
-
3507.
STANDARD
PRIOR
AUTHORIZATIONS.
If
a
health
insurance
issuer
29
requires
prior
authorization
of
a
health
care
service,
the
health
insurance
30
issuer
shall
make
an
approval
or
adverse
determination
and
notify
the
en
-
31
rollee
and
the
enrollee's
health
care
professional
or
health
care
provider
32
of
the
approval
or
adverse
determination
as
expeditiously
as
the
enrollee's
33
condition
requires
but
no
later
than
five
(5)
calendar
days
after
obtaining
34
all
necessary
information
to
make
the
approval
or
adverse
determination,
35
unless
a
longer
minimum
time
frame
is
required
under
federal
law
for
the
36
health
insurance
issuer
and
the
health
care
service
at
issue.
Requests
for
37
information
must
be
reasonably
necessary
to
adjudicate
the
prior
authoriza
-
38
tion
request.
As
used
in
this
section,
"necessary
information"
includes
the
39
results
of
any
face
-
to
-
face
clinical
evaluation,
second
opinion,
or
other
40
clinical
information
that
is
directly
applicable
to
the
requested
service
41
that
may
be
required.
Provided,
however,
health
insurance
issuers
shall
42
respond
within
two
(2)
business
days
for
prior
authorization
requests
for
43
pharmaceutical
services
and
products.
44
41
-
3508.
EXPEDITED
PRIOR
AUTHORIZATIONS.
(1)
If
requested
by
a
treat
-
45
ing
health
care
professional
or
health
care
provider
for
an
enrollee,
a
46
health
insurance
issuer
shall
render
an
approval
or
adverse
determination
47
7
concerning
urgent
health
care
services
and
notify
the
enrollee
and
the
en
-
1
rollee's
health
care
professional
or
health
care
provider
of
that
approval
2
or
adverse
determination
as
expeditiously
as
the
enrollee's
condition
3
requires
but
no
later
than
twenty
-
four
(24)
hours
after
receiving
all
infor
-
4
mation
needed
to
complete
the
review
of
the
requested
health
care
services
5
unless
a
longer
minimum
time
frame
is
required
under
federal
law
for
the
6
health
insurance
issuer
and
the
urgent
health
care
service
at
issue.
7
(2)
To
facilitate
the
rendering
of
a
prior
authorization
determina
-
8
tion
pursuant
to
this
section,
a
health
insurance
issuer
shall
establish
a
9
mechanism
to
ensure
health
care
professionals
have
access
to
appropriately
10
trained
and
licensed
physicians
of
the
same
specialty
for
consultation,
1
1
designated
by
the
issuer
to
make
such
determinations
for
prior
authorization
12
concerning
urgent
care
services.
13
41
-
3509.
NOTIFICATIONS
FOR
ADVERSE
DETERMINATIONS.
If
a
health
in
-
14
surance
issuer
makes
an
adverse
determination,
the
health
insurance
issuer
15
shall
include
the
following
in
the
notification
to
the
enrollee
and
the
en
-
16
rollee's
health
care
professional
or
health
care
provider:
17
(1)
The
reasons
for
the
adverse
determination
and
related
evi
-
18
dence
-
based
criteria,
including
a
description
of
any
missing
or
insuffi
-
19
cient
documentation;
20
(2)
The
right
to
appeal
the
adverse
determination;
21
(3)
Instructions
on
how
to
file
the
appeal;
22
(4)
Additional
documentation
necessary
to
support
the
appeal;
and
23
(5)
The
right
to
request
an
independent
external
review
pursuant
to
the
24
provisions
of
chapter
59,
title
41,
Idaho
Code.
25
41
-
3510.
PERSONNEL
QUALIFIED
TO
REVIEW
APPEALS.
A
health
insurance
26
issuer
shall
ensure
that
all
appeals
are
reviewed
by
a
physician
when
the
27
request
is
made
by
a
physician
or
a
representative
of
a
physician.
The
re
-
28
viewing
physician
shall:
29
(1)
Possess
a
current
and
valid
nonrestricted
license
to
practice
30
medicine
with
substantially
similar
licensing
requirements
to
this
state;
31
(2)
Be
certified
by
the
American
board
of
medical
specialties
or
the
32
American
osteopathic
association
within
the
relevant
specialty
of
a
physi
-
33
cian
who
typically
manages
the
medical
condition
or
disease;
34
(3)
Have
training,
knowledge,
or
experience
of
providing
the
health
35
care
services
under
appeal;
36
(4)
Not
have
been
directly
involved
in
making
the
adverse
determina
-
37
tion;
and
38
(5)
Consider
all
known
clinical
aspects
of
the
health
care
service
un
-
39
der
review,
including
a
review
of
all
pertinent
medical
records
provided
to
40
the
health
insurance
issuer
or
health
care
provider,
the
health
plan's
clin
-
41
ical
guidelines,
and
peer
-
reviewed
scientific
studies.
42
41
-
3511.
INSURER
REVIEW
OF
PRIOR
AUTHORIZATION
REQUIREMENTS.
A
health
43
insurance
issuer
shall
periodically
review
its
prior
authorization
require
-
44
ments
and
consider
removal
of
prior
authorization
requirements.
45
8
41
-
3512.
REVOCATION
OF
PRIOR
AUTHORIZATIONS.
(1)
A
health
insurance
1
issuer
may
not
revoke
or
further
limit,
condition,
or
restrict
a
previously
2
issued
prior
authorization
approval
while
it
remains
valid
in
accordance
3
with
this
chapter
unless:
4
(a)
The
health
insurance
issuer
has
identified
fraudulent
or
abusive
5
practices
related
to
the
health
care
service;
6
(b)
The
health
care
service
is
unavailable,
necessitating
the
use
of
an
7
alternative
health
care
service;
8
(c)
The
health
care
service
is
the
subject
of
a
new
safety
alert
from
the
9
United
States
food
and
drug
administration
or
is
in
response
to
a
public
10
health
emergency;
1
1
(d)
The
change
is
based
on
nationally
recognized
generally
accepted
12
standards
developed
in
accordance
with
current
standards
of
a
national
13
medical
accreditation
entity
or
specialty
society;
or
14
(e)
Changes
to
the
health
care
service
or
its
availability
are
other
-
15
wise
required
by
law
to
be
made
by
the
health
insurance
issuer
within
16
sixty
(60)
days.
17
(2)
Notwithstanding
any
other
provision
of
law,
if
a
claim
is
properly
18
coded
and
submitted
timely
to
a
health
insurance
issuer,
the
health
insur
-
19
ance
issuer
shall
make
payment
according
to
the
terms
of
coverage
on
claims
20
for
health
care
services
for
which
prior
authorization
was
required
and
ap
-
21
proval
received
before
the
provision
of
health
care
services
unless:
22
(a)
It
is
determined
that
the
enrollee's
health
care
professional
or
23
health
care
provider
knowingly
and
without
exercising
prudent
clinical
24
judgment
provided
health
care
services
that
required
prior
authoriza
-
25
tion
from
the
health
insurance
issuer
or
its
contracted
utilization
re
-
26
view
organization
without
first
obtaining
prior
authorization
for
such
27
health
care
services;
28
(b)
It
is
timely
determined
that
the
health
care
services
claimed
were
29
not
performed;
30
(c)
It
is
timely
determined
that
the
health
care
services
provided
by
31
the
enrollee's
health
care
provider
or
health
care
professional
were
32
contrary
to
the
instructions
of
the
health
insurance
issuer
or
its
con
-
33
tracted
utilization
review
organization
if
contact
was
made
between
34
such
parties
before
the
service
being
provided;
35
(d)
It
is
timely
determined
that
the
person
receiving
such
health
care
36
services
was
not
an
enrollee
of
the
health
care
plan;
or
37
(e)
The
approval
was
based
on
a
material
misrepresentation
by
the
en
-
38
rollee,
health
care
professional,
or
health
care
provider.
As
used
in
39
this
paragraph,
"material"
means
a
fact
or
situation
that
would
have
re
-
40
sulted
in
a
substantial
change
in
the
determination
had
it
been
accu
-
41
rately
disclosed
in
the
submission.
42
(3)
Nothing
in
this
section
shall
preclude
a
utilization
review
organi
-
43
zation
or
a
health
insurance
issuer
from
performing
post
-
service
reviews
of
44
health
care
claims
for
purposes
of
payment
integrity
or
for
the
prevention
of
45
fraud,
waste,
or
abuse.
46
41
-
3513.
LENGTH
OF
APPROVALS.
(1)
A
prior
authorization
approval
47
shall
be
valid
for
twelve
(12)
months
after
the
date
the
health
care
profes
-
48
sional
or
health
care
provider
receives
the
prior
authorization
approval.
49
9
Provided,
however,
a
health
insurance
issuer
and
an
enrollee
or
enrollee's
1
health
care
professional
may
extend
a
prior
authorization
approval
for
a
2
longer
period,
by
agreement.
All
dosage
increases
shall
be
based
on
estab
-
3
lished
evidentiary
standards,
and
nothing
in
this
section
shall
prohibit
4
a
health
insurance
issuer
from
having
safety
edits
in
place.
This
section
5
shall
not
apply
to
the
prescription
of
benzodiazepines
or
schedule
II
nar
-
6
cotic
drugs,
such
as
opioids.
7
(2)
Nothing
in
this
section
shall
require
a
policy
or
plan
to
cover
any
8
care,
treatment,
or
services
for
any
health
condition
that
the
terms
of
cov
-
9
erage
otherwise
completely
exclude
from
the
policy's
or
plan's
covered
ben
-
10
efits
without
regard
for
whether
the
care,
treatment,
or
services
are
medi
-
1
1
cally
necessary.
12
41
-
3514.
APPROVALS
FOR
CHRONIC
CONDITIONS.
(1)
If
a
health
insurance
13
issuer
requires
a
prior
authorization
for
a
recurring
health
care
service
14
or
maintenance
medication
for
the
treatment
of
a
chronic
or
long
-
term
condi
-
15
tion,
including
but
not
limited
to
chemotherapy
for
the
treatment
of
cancer,
16
the
approval
shall
remain
valid
for
the
lesser
of
twelve
(12)
months
from
the
17
date
the
health
care
professional
or
health
care
provider
receives
the
au
-
18
thorization
approval
or
the
length
of
the
treatment
as
determined
by
the
pa
-
19
tient's
health
care
professional.
Provided,
however,
a
health
insurance
is
-
20
suer
and
an
enrollee
or
the
enrollee's
health
care
professional
may
extend
a
21
prior
authorization
approval
for
a
longer
period,
by
agreement.
This
sec
-
22
tion
shall
not
apply
to
the
prescription
of
benzodiazepines
or
schedule
II
23
narcotic
drugs,
such
as
opioids.
24
(2)
Nothing
in
this
section
shall
require
a
policy
or
plan
to
cover
any
25
care,
treatment,
or
services
for
any
health
condition
that
the
terms
of
cov
-
26
erage
otherwise
completely
exclude
from
the
policy's
or
plan's
covered
ben
-
27
efits
without
regard
for
whether
the
care,
treatment,
or
services
are
medi
-
28
cally
necessary.
29
41
-
3515.
CONTINUITY
OF
PRIOR
APPROVALS.
(1)
Upon
receipt
of
informa
-
30
tion
documenting
a
prior
authorization
approval
from
the
enrollee
or
from
31
the
enrollee's
health
care
professional
or
health
care
provider,
a
health
32
insurance
issuer
shall
honor
a
prior
authorization
granted
to
an
enrollee
33
from
a
previous
health
insurance
issuer
for
at
least
the
initial
ninety
(90)
34
days
of
an
enrollee's
coverage
under
a
new
health
plan,
subject
to
the
terms
35
of
the
enrollee's
coverage
agreement.
36
(2)
During
the
time
period
described
in
subsection
(1)
of
this
section,
37
a
health
insurance
issuer
may
perform
its
own
review
to
grant
a
prior
autho
-
38
rization
approval,
subject
to
the
terms
of
the
enrollee's
coverage
agree
-
39
ment.
40
(3)
If
there
is
a
change
in
coverage
of
or
approval
criteria
for
a
pre
-
41
viously
authorized
health
care
service,
the
change
in
coverage
or
approval
42
criteria
does
not
affect
an
enrollee
who
received
prior
authorization
before
43
the
effective
date
of
the
change
for
the
remainder
of
the
enrollee's
plan
44
year.
45
(4)
Except
to
the
extent
required
by
medical
exceptions
processes
for
46
prescription
drugs,
nothing
in
this
section
shall
require
a
policy
or
plan
47
to
cover
any
care,
treatment,
or
services
for
any
health
condition
that
the
48
10
terms
of
coverage
otherwise
completely
exclude
from
the
policy's
or
plan's
1
covered
benefits
without
regard
for
whether
the
care,
treatment,
or
services
2
are
medically
necessary.
3
41
-
3516.
EFFECT
OF
INSURER'S
FAILURE
TO
COMPLY.
A
failure
by
a
health
4
insurance
issuer
to
comply
with
the
deadlines
and
other
requirements
speci
-
5
fied
in
this
chapter
shall
result
in
any
health
care
services
subject
to
re
-
6
view
to
be
automatically
deemed
authorized
by
the
health
insurance
issuer
or
7
its
contracted
utilization
review
organization.
8
41
-
3517.
ENFORCEMENT
AND
ADMINISTRATION.
(1)
In
addition
to
the
en
-
9
forcement
powers
granted
to
it
by
law
to
enforce
the
provisions
of
this
chap
-
10
ter,
the
department
is
granted
specific
authority
to
issue
a
cease
-
and
-
de
-
1
1
sist
order
or
require
a
utilization
review
organization
or
health
insurance
12
issuer,
or
both,
to
submit
a
plan
of
correction
for
violations
of
this
chap
-
13
ter.
Subject
to
rules
promulgated
by
the
department
pursuant
to
chapter
52,
14
title
67,
Idaho
Code,
and
after
proper
notice
and
the
opportunity
for
a
hear
-
15
ing,
the
department
may
impose
on
a
utilization
review
organization,
health
16
benefit
plan,
or
health
insurance
issuer
an
administrative
fine
not
to
ex
-
17
ceed
ten
thousand
dollars
($10,000)
per
violation
for
failure
to
submit
a
re
-
18
quested
plan
of
correction,
failure
to
comply
with
its
plan
of
correction,
19
or
repeated
violations
of
this
chapter.
All
fines
collected
by
the
depart
-
20
ment
pursuant
to
this
section
shall
be
deposited
in
the
state
general
fund.
21
The
department
may
also
exercise
all
authority
granted
to
it
under
the
pro
-
22
visions
of
chapter
59,
title
41,
Idaho
Code,
to
deny
or
revoke
approval
of
a
23
utilization
review
organization
for
a
violation
of
this
chapter.
24
(2)
An
enrollee
or
an
enrollee's
health
care
provider
who
has
evidence
25
that
the
enrollee's
health
insurance
issuer
or
health
benefit
plan
is
in
26
violation
of
the
provisions
of
this
chapter
may
file
a
complaint
with
the
27
department.
The
department
shall
review
all
complaints
received
and
in
-
28
vestigate
all
complaints
that
it
deems
to
state
a
potential
violation.
The
29
department
shall
fairly,
efficiently,
and
timely
review
and
investigate
30
complaints
and
shall
provide
the
subject
of
the
complaint
an
opportunity
to
31
refute
the
evidence
against
it.
Health
insurance
issuers,
health
benefit
32
plans,
and
utilization
review
organizations
found
to
be
in
violation
of
this
33
chapter
shall
be
penalized
in
accordance
with
this
section.
34
(3)
There
shall
be
no
private
right
of
action
under
this
chapter.
35
41
-
3518.
REPORTS
TO
THE
DEPARTMENT.
(1)
By
June
1,
2027,
and
each
June
36
1
thereafter,
a
health
insurance
issuer
shall
report
to
the
department,
on
a
37
form
issued
by
the
department,
the
following
aggregated
trend
data,
de
-
iden
-
38
tified
of
protected
health
information,
related
to
the
insurer's
practices
39
and
experience
for
the
prior
plan
year
for
health
care
services
submitted
for
40
payment:
41
(a)
The
number
of
prior
authorization
requests;
42
(b)
The
percentage
of
prior
authorization
requests
denied;
43
(c)
The
percentage
of
prior
authorization
appeals
received;
44
(d)
The
percentage
of
adverse
determinations
reversed
on
appeal;
45
(e)
The
percentage
of
prior
authorization
requests
that
were
not
sub
-
46
mitted
electronically;
47
11
(f)
As
a
percentage
by
service,
the
ten
(10)
health
care
services
that
1
were
most
frequently
denied
through
prior
authorization;
and
2
(g)
The
five
(5)
reasons
prior
authorization
requests
were
most
fre
-
3
quently
denied.
4
(2)
All
reports
required
by
this
section
shall
be
considered
public
5
records
pursuant
to
chapter
1,
title
74,
Idaho
Code,
and
the
department
shall
6
make
all
reports
freely
available
to
requestors
and
post
all
reports
to
its
7
public
website
without
redactions.
8
41
-
3519.
FALSE
REQUESTS
FOR
PRIOR
AUTHORIZATION.
If
a
health
insur
-
9
ance
issuer
has
clear
and
convincing
evidence
that
a
health
care
profes
-
10
sional
or
health
care
provider
has
knowingly
and
willfully
submitted
false
1
1
or
fraudulent
requests
for
prior
authorization
to
the
health
insurance
is
-
12
suer,
the
issuer
shall
notify
and
provide
that
information
to
the
department
13
director.
After
receipt
of
such
notification
and
information,
the
director
14
shall
forward
these
reports
to
the
board
of
medicine
or
such
other
licensing
15
agency
with
oversight
of
the
health
care
provider
and
to
the
office
of
the
16
prosecuting
authority
having
jurisdiction.
17
41
-
3520.
RULES.
The
department
shall
have
the
authority
to
promulgate
18
rules,
subject
to
legislative
approval,
pursuant
to
the
provisions
of
chap
-
19
ter
52,
title
67,
Idaho
Code,
to
govern
the
administration
of
this
chapter.
20
SECTION
2.
An
emergency
existing
therefor,
which
emergency
is
hereby
21
declared
to
exist,
this
act
shall
be
in
full
force
and
effect
on
and
after
22
July
1,
2026.
23