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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.
841
BY
WAYS
AND
MEANS
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
PROVIDE
FOR
APPLICABILITY
AND
SCOPE,
TO
DEFINE
5
TERMS,
TO
PROVIDE
FOR
DISCLOSURE
AND
REVIEW
OF
PRIOR
AUTHORIZATION
RE
-
6
QUIREMENTS,
TO
PROVIDE
FOR
PRIOR
AUTHORIZATION
APPLICATION
PROGRAMMING
7
INTERFACE,
TO
PROVIDE
FOR
STANDARD
PRIOR
AUTHORIZATIONS,
TO
PROVIDE
8
FOR
EXPEDITED
PRIOR
AUTHORIZATIONS,
TO
PROVIDE
FOR
NOTIFICATIONS
FOR
9
ADVERSE
DETERMINATIONS,
TO
PROVIDE
FOR
PERSONNEL
QUALIFIED
TO
REVIEW
10
APPEALS,
TO
PROVIDE
FOR
INSURER
REVIEW
OF
PRIOR
AUTHORIZATION
REQUIRE
-
1
1
MENTS,
TO
PROVIDE
FOR
REVOCATION
OF
PRIOR
AUTHORIZATIONS,
TO
PROVIDE
12
FOR
THE
LENGTH
OF
APPROVALS,
TO
PROVIDE
FOR
APPROVALS
FOR
CHRONIC
CONDI
-
13
TIONS,
TO
PROVIDE
FOR
CONTINUITY
OF
PRIOR
APPROVALS,
TO
PROVIDE
FOR
EN
-
14
FORCEMENT
AND
ADMINISTRATION,
TO
PROVIDE
FOR
REPORTS
TO
THE
DEPARTMENT
15
OF
INSURANCE,
TO
PROVIDE
FOR
FALSE
REQUESTS
FOR
PRIOR
AUTHORIZATION,
TO
16
PROVIDE
FOR
A
DE
MINIMIS
PRIOR
AUTHORIZATION
UTILIZATION
EXEMPTION,
AND
17
TO
PROVIDE
RULEMAKING
AUTHORITY;
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
is
-
35
suers
of
health
benefit
plans,
to
all
incorporated
or
stand
-
alone
dental
36
benefit
plans,
and
to
all
utilization
reviews
and
utilization
review
orga
-
37
nizations,
as
defined
in
section
41
-
5903,
Idaho
Code,
except
for
employee
38
or
employer
self
-
insured
health
benefit
plans
under
the
federal
employee
39
2
retirement
income
security
act
of
1974,
health
care
provided
pursuant
to
1
worker's
compensation
law,
or
prescription
drugs,
biologics,
biosimilars,
2
and
pharmaceutical
medicines.
This
chapter
does
not
diminish
the
duties
and
3
responsibilities
under
other
federal
or
state
law
or
rules
promulgated
under
4
those
laws
applicable
to
a
health
insurer,
health
insurance
issuer,
health
5
benefit
plan,
utilization
review
plan,
or
utilization
review
organization.
6
41
-
3504.
DEFINITIONS.
For
the
purposes
of
this
chapter:
7
(1)
"Adverse
determination"
means
a
determination
by
a
health
insur
-
8
ance
issuer
that,
based
on
the
information
provided,
a
pre
-
service
request
9
for
a
benefit
under
the
health
insurance
issuer's
health
benefit
plan
upon
10
application
of
any
utilization
review
technique
does
not
meet
the
health
1
1
insurance
issuer's
requirements
for
medical
necessity,
appropriateness,
12
health
care
setting,
level
of
care,
or
effectiveness
or
is
determined
to
be
13
experimental
or
investigational,
and
the
requested
benefit
is
therefore
14
denied.
15
(2)
"Appeal"
means
a
formal
request,
either
orally
or
in
writing,
to
re
-
16
consider
an
adverse
determination.
17
(3)
"Approval"
means
a
determination
by
a
health
insurance
issuer
that
18
a
health
care
service
has
been
reviewed
and,
based
on
the
information
pro
-
19
vided,
satisfies
the
health
insurance
issuer's
requirements
for
medical
ne
-
20
cessity
and
appropriateness.
21
(4)
"Clinical
review
criteria"
means
the
written
screening
procedures,
22
decision
abstracts,
clinical
protocols,
and
practice
guidelines
used
by
a
23
health
insurance
issuer
to
determine
the
necessity
and
appropriateness
of
24
health
care
services.
25
(5)
"Complete
prior
authorization
request"
means
a
prior
authorization
26
request
that:
27
(a)
Is
submitted
by
a
health
care
professional
or
health
care
provider
28
in
accordance
with
the
standardized
electronic
prior
authorization
29
process
required
by
this
chapter,
if
applicable;
30
(b)
Includes
all
clinical
documentation,
diagnostic
results,
and
other
31
information
reasonably
required
by
the
health
insurance
issuer's
pub
-
32
licly
disclosed
clinical
review
criteria
in
effect
at
the
time
the
re
-
33
quest
is
submitted;
34
(c)
Requires
no
additional
information
from
the
enrollee,
the
35
provider,
or
a
third
party
that
is
reasonably
necessary
to
adjudicate
36
the
request;
and
37
(d)
Complies
with
the
health
insurance
issuer's
published
prior
autho
-
38
rization
submission
standards
in
effect
at
the
time
the
request
is
sub
-
39
mitted.
40
(6)
"Dentist"
means
any
person
with
a
valid
doctor
of
dental
surgery,
41
doctor
of
medicine
in
dentistry,
or
doctor
of
dental
medicine
degree.
42
(7)
"Department"
means
the
Idaho
department
of
insurance.
43
(8)
"Emergency
medical
condition"
means
a
medical
condition
manifest
-
44
ing
itself
by
acute
symptoms
of
sufficient
severity,
including
but
not
lim
-
45
ited
to
severe
pain,
such
that
a
prudent
layperson
who
possesses
an
average
46
knowledge
of
health
and
medicine
could
reasonably
expect
the
absence
of
im
-
47
mediate
medical
attention
to
result
in:
48
3
(a)
Placing
the
health
of
the
individual
or,
with
respect
to
a
pregnant
1
woman,
the
health
of
the
woman
or
her
unborn
child,
in
serious
jeopardy;
2
(b)
Serious
impairment
to
bodily
functions;
or
3
(c)
Serious
dysfunction
of
any
bodily
organ
or
part.
4
(9)
"Emergency
services"
means
health
care
items
and
services
fur
-
5
nished
or
required
to
evaluate
and
treat
an
emergency
medical
condition.
6
(10)
"Enrollee"
means
any
person
and
the
person's
dependents
enrolled
7
in
or
covered
by
a
health
care
plan.
8
(11)(a)
"Expedited
prior
authorization
request"
means
a
pre
-
service
or
9
concurrent
care
claim
for
medical
care
or
treatment
for
which
applica
-
10
tion
of
the
time
periods
for
making
a
non
-
expedited
prior
authorization
1
1
could,
in
the
opinion
of
a
treating
health
care
professional
or
health
12
care
provider
with
knowledge
of
the
enrollee's
medical
condition:
13
(i)
Seriously
jeopardize
the
life
or
health
of
the
enrollee
or
the
14
ability
of
the
enrollee
to
regain
maximum
function;
15
(ii)
Subject
the
enrollee
to
severe
pain
that
cannot
be
adequately
16
managed
without
the
care
or
treatment
that
is
the
subject
of
the
17
authorization
request;
or
18
(iii)
Lead
to
likely
onset
of
an
emergency
medical
condition
if
the
19
service
is
not
rendered
during
the
time
period
to
render
a
prior
20
authorization
determination
for
an
urgent
medical
service.
21
(b)
"Expedited
prior
authorization
request"
does
not
apply
to
emer
-
22
gency
services.
23
(12)
"Health
care
professional"
means
a
physician,
a
registered
pro
-
24
fessional
nurse,
a
dentist,
or
another
individual
appropriately
licensed
or
25
registered
to
provide
health
care
services.
26
(13)
"Health
care
provider"
means
any
physician,
dentist,
hospital,
am
-
27
bulatory
surgery
center,
or
other
person
or
facility
that
is
licensed
or
oth
-
28
erwise
authorized
to
deliver
health
care
services.
29
(14)
"Health
care
service"
means
any
services
or
level
of
services
in
-
30
cluded
in
the
furnishing
of
medical
or
dental
care
to
an
individual
or
the
31
hospitalization
incident
to
the
furnishing
of
such
care,
as
well
as
the
fur
-
32
nishing
of
any
other
services
to
any
person
for
the
purpose
of
preventing,
33
alleviating,
curing,
or
healing
human
illness
or
injury,
including
behav
-
34
ioral
health,
mental
health,
and
home
health,
and
pharmaceutical
services,
35
products,
and
medications.
36
(15)
"Health
insurance
issuer"
means
the
issuer
of
a
health
benefit
plan
37
or
dental
benefit
plan.
38
(16)
"Medically
necessary"
means
care
that
a
health
care
professional
39
exercising
prudent
clinical
judgment
would
provide
to
a
patient
for
the
pur
-
40
pose
of
preventing,
diagnosing,
or
treating
an
illness,
injury,
disease,
or
41
its
symptoms
and
that
is:
42
(a)
In
accordance
with
generally
accepted
standards
of
medical
prac
-
43
tice
or
dental
practice;
44
(b)
Clinically
appropriate
in
terms
of
type,
frequency,
extent,
site,
45
and
duration
and
considered
effective
for
the
patient's
illness,
in
-
46
jury,
or
disease;
47
(c)
Focused
on
what
is
best
for
the
patient's
health
outcome;
and
48
4
(d)
Not
primarily
for
the
convenience
of
the
patient,
treating
physi
-
1
cian,
other
health
care
professional,
caregiver,
family
member,
or
2
other
interested
party.
3
(17)
"Physician"
means
any
person
with
a
valid
doctor
of
medicine,
doc
-
4
tor
of
osteopathy,
or
doctor
of
podiatry
degree.
5
(18)
"Prior
authorization"
means
the
process
by
which
a
health
insur
-
6
ance
issuer
determines
the
medical
necessity
and
medical
appropriateness
of
7
an
otherwise
covered
health
care
service
before
the
rendering
of
such
health
8
care
service.
While
not
requiring
explicit
approval,
any
notification
re
-
9
quired
of
an
enrollee,
health
care
professional,
or
health
care
provider
by
10
the
health
insurance
issuer
before,
at
the
time
of,
or
concurrent
to
provid
-
1
1
ing
a
health
care
service
shall
be
included
within
the
definition
of
"prior
12
authorization."
Any
pre
-
service
review
that
is
used
to
evaluate
clinical
ne
-
13
cessity,
regardless
of
the
terminology
used
to
describe
such
pre
-
service
re
-
14
view,
falls
within
this
definition,
including
but
not
limited
to
predetermi
-
15
nation,
pretreatment,
and
preauthorization.
16
(19)
"Urgent
health
care
services"
means
those
services
that,
if
not
17
provided
to
an
enrollee,
could
seriously
jeopardize
the
enrollee's
life,
18
health,
or
ability
to
regain
maximum
function.
19
(20)
"Utilization
review
organization"
has
the
meaning
given
to
that
20
term
in
section
41
-
5903,
Idaho
Code.
21
41
-
3505.
DISCLOSURE
AND
REVIEW
OF
PRIOR
AUTHORIZATION
REQUIRE
-
22
MENTS.
(1)
A
health
insurance
issuer
shall
maintain
a
complete
list
of
23
services
for
which
prior
authorization
is
required,
including
for
all
ser
-
24
vices
where
prior
authorization
is
performed
by
an
entity
under
contract
25
with
the
health
insurance
issuer.
26
(2)
A
health
insurance
issuer
shall
make
any
current
prior
authoriza
-
27
tion
requirements
and
restrictions,
including
the
written
clinical
review
28
criteria,
readily
accessible
and
conspicuously
posted
on
its
website
or
29
online
portal
to
enrollees,
health
care
professionals,
and
health
care
30
providers.
Content
published
by
a
third
party
and
licensed
for
use
by
a
31
health
insurance
issuer
may
be
made
available
through
the
health
insurance
32
issuer's
secure,
password
-
protected
website
or
online
portal
as
long
as
the
33
access
requirements
of
the
website
do
not
unreasonably
restrict
access.
34
Requirements
shall
be
described
in
detail,
written
in
easily
understandable
35
language,
and
readily
available
to
the
health
care
professional
and
health
36
care
provider
at
the
point
of
care.
The
website
or
online
portal
shall
indi
-
37
cate
for
each
service
subject
to
prior
authorization:
38
(a)
The
date
on
which
prior
authorization
became
required
for
policies
39
issued
or
health
benefit
plan
documents
delivered
in
Idaho,
including
40
the
effective
dates
and
the
termination
dates,
if
applicable,
in
Idaho;
41
(b)
The
date
on
which
the
Idaho
-
specific
requirement
was
listed
on
the
42
website
or
online
portal
of
the
health
insurance
issuer;
43
(c)
If
applicable,
the
date
on
which
the
prior
authorization
require
-
44
ment
was
removed
for
Idaho;
and
45
(d)
If
applicable,
access
to
a
standardized
electronic
prior
autho
-
46
rization
request
transaction
process.
47
(3)
The
clinical
review
criteria
must:
48
5
(a)
Be
consistent
with
nationally
accepted
standards
generally
recog
-
1
nized
by
physicians
and
health
care
providers
practicing
in
relevant
2
medical
and
clinical
specialties
except
where
state
law
provides
its
3
own
standard;
4
(b)
Be
developed
in
accordance
with
the
current
standards
of
a
national
5
medical
accreditation
entity;
6
(c)
Ensure
quality
of
care
and
access
to
needed
health
care
services;
7
(d)
Be
based
on
evidence
from
sources,
including
peer
-
reviewed
scien
-
8
tific
studies;
9
(e)
Be
sufficiently
flexible
to
allow
deviations
from
norms
when
justi
-
10
fied
on
a
case
-
by
-
case
basis;
and
1
1
(f)
Be
evaluated
and
updated
at
least
annually
under
the
direction
of
a
12
physician
who:
13
(i)
Possesses
a
current,
valid,
and
unrestricted
license
to
prac
-
14
tice
medicine
in
Idaho
or
in
a
state
with
substantially
similar
li
-
15
censing
requirements;
and
16
(ii)
Has
knowledge
of
the
standard
of
care
in
the
community
where
17
care
is
proposed
to
be
provided.
18
(4)
A
health
insurance
issuer
shall
not
deny
a
claim
for
failure
to
ob
-
19
tain
prior
authorization
if
the
prior
authorization
requirement
was
not
in
20
effect
on
the
date
of
service
or
if
the
claim
or
prior
authorization
require
-
21
ments
were
not
publicly
disclosed
by
the
plan
on
the
health
insurance
is
-
22
suer's
website,
online
portal,
or
other
materials.
23
(5)
If
a
health
insurance
issuer
intends
either
to
implement
a
new
prior
24
authorization
requirement
or
restriction
or
to
amend
an
existing
require
-
25
ment
or
restriction,
the
health
insurance
issuer
shall
provide
impacted
26
enrollees,
contracted
health
care
professionals,
and
contracted
health
care
27
providers
of
enrollees
written
notice
of
the
new
or
amended
requirement
no
28
less
than
sixty
(60)
days
before
the
requirement
or
restriction
is
imple
-
29
mented.
Written
notice
may
take
the
form
of
a
conspicuous
notice
posted
30
on
the
health
insurance
issuer's
public
website
or
online
portal
for
con
-
31
tracted
health
care
professionals
and
contracted
health
care
providers
or
32
email
notice
to
health
care
professionals
or
health
care
providers.
A
health
33
insurance
issuer
shall
provide
email
notices
to
all
impacted
enrollees
and
34
to
health
care
professionals
or
health
care
providers
if
the
health
care
35
professional
or
health
care
provider
has
requested
to
receive
the
notice
36
through
email.
A
new
or
amended
requirement
shall
not
be
implemented
unless
37
the
health
insurance
issuer's
website
or
online
portal
has
been
updated
to
38
reflect
the
new
or
amended
requirement
or
restriction.
Written
notice
of
a
39
new,
amended,
or
restricted
prior
authorization
requirement
may
be
provided
40
less
than
sixty
(60)
days
in
advance
of
implementation
if
a
health
insurance
41
issuer
determines
and
contemporaneously
notifies
the
department
in
writing
42
that:
43
(a)
The
health
insurance
issuer
has
identified
fraudulent
or
abusive
44
practices
related
to
the
health
care
service;
45
(b)
The
health
care
service
is
unavailable
or
scarce,
necessitating
the
46
use
of
an
alternative
health
care
service;
47
(c)
The
health
care
service
is
newly
introduced
to
the
health
care
mar
-
48
ket
and
a
delay
in
providing
coverage
for
the
health
care
service
would
49
not
be
in
the
best
interests
of
enrollees;
50
6
(d)
The
health
care
service
is
the
subject
of
a
clinical
trial
autho
-
1
rized
by
the
United
States
food
and
drug
administration;
2
(e)
Changes
to
the
health
care
service
or
its
availability
are
other
-
3
wise
required
by
law
to
be
made
by
the
health
insurance
issuer
in
less
4
than
sixty
(60)
days;
or
5
(f)
The
prior
authorization
requirement
is
being
removed.
6
(6)
Health
insurance
issuers
using
prior
authorization
shall
make
sta
-
7
tistics
available
regarding
prior
authorization
approvals
and
denials
on
8
their
website
or
online
portal
in
a
readily
accessible
format.
The
reporting
9
requirements
of
this
subsection
shall
be
implemented
in
a
manner
consistent
10
with
the
public
reporting
requirements
established
under
the
centers
for
1
1
medicare
and
medicaid
services
(CMS)
interoperability
and
prior
authoriza
-
12
tion
final
rule
(CMS
-
0057
-
F),
as
amended,
to
the
extent
applicable.
13
(7)
The
implementation
requirements
of
this
section
shall
commence
by
14
January
1,
2027.
Health
insurance
issuers
may
comply
with
the
implementa
-
15
tion
requirements
of
this
section
in
phases,
consistent
with
applicable
fed
-
16
eral
interoperability
timelines.
17
41
-
3506.
PRIOR
AUTHORIZATION
APPLICATION
PROGRAMMING
INTERFACE.
(1)
18
If
a
health
insurance
issuer
requires
prior
authorization
of
a
health
care
19
service,
the
issuer
or
its
contracted
utilization
review
organization
20
shall,
to
the
extent
required
under
applicable
federal
interoperability
21
requirements,
and
by
January
1,
2027,
implement
and
maintain
a
prior
autho
-
22
rization
application
programming
interface
(API).
23
(2)
The
API
shall:
24
(a)
Conform
to
the
applicable
interoperability
standards
adopted
by
25
the
centers
for
medicare
and
medicaid
services
(CMS)
in
the
CMS
inter
-
26
operability
and
prior
authorization
final
rule
(CMS
-
0057
-
F),
including
27
health
level
7
fast
healthcare
interoperability
resources
release
28
4.0.1
or
a
successor
version
adopted
by
CMS;
29
(b)
Be
capable
of
identifying,
for
items
and
services
excluding
pre
-
30
scription
drugs
unless
otherwise
required
by
federal
law,
whether
prior
31
authorization
is
required;
32
(c)
Identify
payer
-
specific
documentation
requirements
for
each
item
33
or
service
that
requires
prior
authorization;
34
(d)
Support
the
electronic
creation
and
exchange
of
prior
authoriza
-
35
tion
requests
and
responses
between
health
care
professionals,
health
36
care
providers,
and
the
health
insurance
issuer;
and
37
(e)
Be
implemented
in
a
manner
that
does
not
disrupt
compliance
with
38
federal
interoperability
requirements.
39
(3)
A
health
insurance
issuer
may
use
an
updated
version
of
a
required
40
interoperability
standard
if
such
use
is
consistent
with
federal
law
and
41
does
not
disrupt
an
end
user's
ability
to
access
required
data.
42
(4)
Nothing
in
this
section
shall
require
the
creation
of
an
Idaho
-
spe
-
43
cific
electronic
prior
authorization.
44
(5)
For
the
purposes
of
this
chapter,
a
prior
authorization
request
45
shall
be
deemed
received
only
upon
submission
of
a
complete
prior
authoriza
-
46
tion
request.
47
(a)
A
request
shall
be
considered
complete
when
the
health
insurance
48
issuer
has
received
all
documentation
and
information
reasonably
nec
-
49
7
essary
to
make
a
determination
under
the
terms
of
the
health
benefit
1
plan.
2
(b)
A
prior
authorization
request
shall
not
fail
to
meet
the
definition
3
of
a
complete
prior
authorization
request
due
to
minor
clerical
or
tech
-
4
nical
errors
that
do
not
materially
affect
the
ability
of
the
health
in
-
5
surance
issuer
to
make
a
determination.
6
(c)
A
prior
authorization
request
shall
be
presumed
complete
unless
the
7
health
insurance
issuer
provides
written
notice
within
one
(1)
business
8
day
of
receipt
specifying
with
particularity
any
additional
informa
-
9
tion
reasonably
necessary
to
adjudicate
the
request.
10
41
-
3507.
STANDARD
PRIOR
AUTHORIZATIONS.
(1)
If
a
health
insurance
1
1
issuer
requires
prior
authorization
of
a
health
care
service,
the
health
12
insurance
issuer
shall
render
a
decision
and
notify
the
enrollee
and
the
en
-
13
rollee's
health
care
professional
or
health
care
provider
as
expeditiously
14
as
the
enrollee's
condition
requires
but
no
later
than
seven
(7)
calen
-
15
dar
days
after
receipt
of
a
complete
prior
authorization
request,
unless
a
16
longer
time
frame
is
required
under
applicable
federal
law.
Requests
for
17
additional
information
must
be
reasonably
necessary
to
adjudicate
the
prior
18
authorization
request.
As
used
in
this
section,
"additional
information"
19
may
include
the
results
of
any
face
-
to
-
face
clinical
evaluation,
a
second
20
opinion,
or
any
other
clinical
information
that
is
directly
applicable
to
21
the
requested
service
as
may
be
required.
22
(2)
If
a
health
insurance
issuer
determines
that
a
prior
authorization
23
request
is
incomplete,
the
health
insurance
issuer
shall
notify
the
health
24
care
professional
or
health
care
provider
within
one
(1)
business
day
and
25
shall
specify
in
writing
the
information
reasonably
necessary
to
complete
26
the
request.
The
health
insurance
issuer
may
request
additional
information
27
only
once
per
prior
authorization
request
unless
the
health
care
provider
28
submits
materially
new
clinical
information.
29
41
-
3508.
EXPEDITED
PRIOR
AUTHORIZATIONS.
(1)
If
requested
by
a
treat
-
30
ing
health
care
professional
or
health
care
provider
for
an
enrollee,
a
31
health
insurance
issuer
shall
render
a
decision
concerning
urgent
health
32
care
services
as
expeditiously
as
the
enrollee's
condition
requires,
but
33
no
later
than
seventy
-
two
(72)
hours
after
receipt
of
a
complete
expedited
34
prior
authorization
request,
unless
a
longer
time
frame
is
required
pursuant
35
to
applicable
federal
law.
36
(2)
To
facilitate
the
rendering
of
a
prior
authorization
determina
-
37
tion
pursuant
to
this
section,
a
health
insurance
issuer
shall
establish
a
38
mechanism
to
ensure
health
care
professionals
have
access
to
appropriately
39
trained
and
licensed
physicians
preferably
but
not
necessarily
of
the
same
40
specialty
for
consultation,
designated
by
the
health
insurance
issuer
to
41
make
such
determinations
for
prior
authorization
concerning
urgent
care
42
services.
43
41
-
3509.
NOTIFICATIONS
FOR
ADVERSE
DETERMINATIONS.
If
a
health
in
-
44
surance
issuer
makes
an
adverse
determination,
the
health
insurance
issuer
45
shall
include
the
following
in
the
notification
to
the
enrollee
and
the
en
-
46
rollee's
health
care
professional
or
health
care
provider:
47
8
(1)
The
reasons
for
the
adverse
determination
and
related
evi
-
1
dence
-
based
criteria,
including
a
description
of
any
missing
or
insuffi
-
2
cient
documentation;
3
(2)
The
right
to
appeal
the
adverse
determination;
4
(3)
Instructions
on
how
to
file
the
appeal;
5
(4)
Additional
documentation
necessary
to
support
the
appeal;
and
6
(5)
The
right
to
request
an
independent
external
review
pursuant
to
the
7
provisions
of
chapter
59,
title
41,
Idaho
Code.
8
41
-
3510.
PERSONNEL
QUALIFIED
TO
REVIEW
APPEALS.
A
health
insurance
9
issuer
shall
ensure
that
all
appeals
are
peer
reviewed
by
an
appropriate
10
licensed
health
care
professional
in
the
same
or
substantially
similar
field
1
1
or
specialty.
The
reviewing
health
care
professional
shall:
12
(1)
Possess
a
current
and
valid
nonrestricted
license
to
practice
13
medicine
with
substantially
similar
licensing
requirements
to
this
state;
14
(2)
Be
certified
by
the
American
board
of
medical
specialties
or
the
15
American
osteopathic
association
within
the
relevant
specialty
of
a
physi
-
16
cian
who
typically
manages
the
medical
condition
or
disease;
17
(3)
Have
training,
knowledge,
or
experience
of
providing
the
health
18
care
services
under
appeal;
19
(4)
Not
have
been
directly
involved
in
making
the
adverse
determina
-
20
tion;
and
21
(5)
Consider
all
known
clinical
aspects
of
the
health
care
service
un
-
22
der
review,
including
a
review
of
all
pertinent
medical
records
provided
to
23
the
health
insurance
issuer
or
health
care
provider,
the
health
plan's
clin
-
24
ical
guidelines,
and
peer
-
reviewed
scientific
studies.
25
41
-
3511.
INSURER
REVIEW
OF
PRIOR
AUTHORIZATION
REQUIREMENTS.
A
health
26
insurance
issuer
shall
periodically
review
its
prior
authorization
require
-
27
ments
and
consider
removal
of
prior
authorization
requirements.
28
41
-
3512.
REVOCATION
OF
PRIOR
AUTHORIZATIONS.
(1)
A
health
insurance
29
issuer
may
not
revoke
or
further
limit,
condition,
or
restrict
a
previously
30
issued
prior
authorization
approval
while
it
remains
valid
in
accordance
31
with
this
chapter
unless:
32
(a)
The
health
insurance
issuer
has
identified
fraudulent
or
abusive
33
practices
related
to
the
health
care
service;
34
(b)
The
health
care
service
is
unavailable,
necessitating
the
use
of
an
35
alternative
health
care
service;
36
(c)
The
health
care
service
is
the
subject
of
a
new
safety
alert
from
the
37
United
States
food
and
drug
administration
or
is
in
response
to
a
public
38
health
emergency;
39
(d)
The
change
is
based
on
nationally
recognized
generally
accepted
40
standards
developed
in
accordance
with
current
standards
of
a
national
41
medical
accreditation
entity
or
specialty
society;
42
(e)
Changes
to
the
health
care
service
or
its
availability
are
other
-
43
wise
required
by
law
to
be
made
by
the
health
insurance
issuer
within
44
sixty
(60)
days;
or
45
(f)
There
is
a
material
change
in
clinical
circumstances
that
is
sup
-
46
ported
by
documented
medical
evidence.
47
9
(2)
Notwithstanding
any
other
provision
of
law,
if
a
claim
is
properly
1
coded
and
timely
submitted
to
a
health
insurance
issuer,
the
health
insur
-
2
ance
issuer
shall
make
payment
according
to
the
terms
of
coverage
on
claims
3
for
health
care
services
for
which
prior
authorization
was
required
and
ap
-
4
proval
received
before
the
provision
of
health
care
services
unless:
5
(a)
It
is
determined
that
the
enrollee's
health
care
professional
or
6
health
care
provider
knowingly
and
without
exercising
prudent
clinical
7
judgment
provided
health
care
services
that
required
prior
authoriza
-
8
tion
from
the
health
insurance
issuer
or
its
contracted
utilization
re
-
9
view
organization
without
first
obtaining
prior
authorization
for
such
10
health
care
services;
1
1
(b)
It
is
timely
determined
that
the
health
care
services
claimed
were
12
not
performed;
13
(c)
It
is
timely
determined
that
the
health
care
services
provided
by
14
the
enrollee's
health
care
professional
or
health
care
provider
were
15
contrary
to
the
instructions
of
the
health
insurance
issuer
or
its
con
-
16
tracted
utilization
review
organization
if
contact
was
made
between
17
such
parties
before
the
health
care
services
being
provided;
18
(d)
It
is
timely
determined
that
the
person
receiving
such
health
care
19
services
was
not
an
enrollee
of
the
health
care
plan;
or
20
(e)
The
approval
was
based
on
a
material
misrepresentation
by
the
en
-
21
rollee,
health
care
professional,
or
health
care
provider.
As
used
in
22
this
paragraph,
"material"
means
a
fact
or
situation
that
would
have
re
-
23
sulted
in
a
substantial
change
in
the
determination
had
it
been
accu
-
24
rately
disclosed
in
the
submission.
25
(3)
Nothing
in
this
section
shall
preclude
a
health
insurance
issuer
or
26
a
utilization
review
organization
from
performing
post
-
service
reviews
of
27
health
care
claims
for
purposes
of
payment
integrity
or
for
the
prevention
of
28
fraud,
waste,
or
abuse.
29
41
-
3513.
LENGTH
OF
APPROVALS.
(1)
A
prior
authorization
approval
30
shall
be
valid
for
six
(6)
months
after
the
date
the
health
care
profes
-
31
sional
or
health
care
provider
receives
the
prior
authorization
approval.
32
Provided,
however,
a
health
insurance
issuer
and
an
enrollee
or
enrollee's
33
health
care
professional
may
extend
a
prior
authorization
approval
for
a
34
longer
period,
by
agreement.
35
(2)
Nothing
in
this
section
shall
require
a
policy
or
plan
to
cover
any
36
care,
treatment,
or
services
for
any
health
condition
that
the
terms
of
cov
-
37
erage
otherwise
completely
exclude
from
the
policy's
or
plan's
covered
ben
-
38
efits
without
regard
for
whether
the
care,
treatment,
or
services
are
medi
-
39
cally
necessary.
40
41
-
3514.
APPROVALS
FOR
CHRONIC
CONDITIONS.
(1)
If
a
health
insurance
41
issuer
requires
a
prior
authorization
for
a
recurring
health
care
service
42
for
the
treatment
of
a
chronic
or
long
-
term
condition,
the
approval
shall
re
-
43
main
valid
for
the
lesser
of
twelve
(12)
months
from
the
date
the
health
care
44
professional
or
health
care
provider
receives
the
authorization
approval
or
45
the
length
of
the
treatment
as
determined
by
the
patient's
health
care
pro
-
46
fessional.
Provided,
however,
a
health
insurance
issuer
and
an
enrollee
or
47
10
the
enrollee's
health
care
professional
may
extend
a
prior
authorization
ap
-
1
proval
for
a
longer
period,
by
agreement.
2
(2)
Nothing
in
this
section
shall
require
a
policy
or
plan
to
cover
any
3
care,
treatment,
or
services
for
any
health
condition
that
the
terms
of
cov
-
4
erage
otherwise
completely
exclude
from
the
policy's
or
plan's
covered
ben
-
5
efits
without
regard
for
whether
the
care,
treatment,
or
services
are
medi
-
6
cally
necessary.
7
41
-
3515.
CONTINUITY
OF
PRIOR
APPROVALS.
(1)
Upon
receipt
of
informa
-
8
tion
documenting
a
prior
authorization
approval
from
the
enrollee
or
from
9
the
enrollee's
health
care
professional
or
health
care
provider,
a
health
10
insurance
issuer
shall
honor
a
prior
authorization
granted
to
an
enrollee
1
1
from
a
previous
health
insurance
issuer
for
at
least
the
initial
ninety
(90)
12
days
of
an
enrollee's
coverage
under
a
new
health
plan,
subject
to
the
terms
13
of
the
enrollee's
coverage
agreement.
14
(2)
During
the
time
period
described
in
subsection
(1)
of
this
section,
15
a
health
insurance
issuer
may
perform
its
own
review
to
grant
a
prior
autho
-
16
rization
approval,
subject
to
the
terms
of
the
enrollee's
coverage
agree
-
17
ment.
18
(3)
Nothing
in
this
chapter
shall
require
a
policy
or
plan
to
cover
any
19
care,
treatment,
or
services
for
any
health
condition
that
the
terms
of
cov
-
20
erage
otherwise
completely
exclude
from
the
policy's
or
plan's
covered
ben
-
21
efits
without
regard
for
whether
the
care,
treatment,
or
services
are
medi
-
22
cally
necessary.
23
(4)
Nothing
in
this
chapter
shall
prevent
a
health
insurance
issuer
to
24
engage
an
enrollee
with
an
option
to
consider
clinically
appropriate
alter
-
25
natives.
26
41
-
3516.
ENFORCEMENT
AND
ADMINISTRATION.
(1)
In
addition
to
the
en
-
27
forcement
powers
granted
to
it
by
law
to
enforce
the
provisions
of
this
chap
-
28
ter,
the
department
is
granted
specific
authority
to
issue
a
cease
-
and
-
de
-
29
sist
order
or
require
a
health
insurance
issuer
or
utilization
review
organ
-
30
ization,
or
both,
to
submit
a
plan
of
correction
for
violations
of
this
chap
-
31
ter.
Subject
to
rules
promulgated
by
the
department
pursuant
to
chapter
52,
32
title
67,
Idaho
Code,
and
after
proper
notice
and
the
opportunity
for
a
hear
-
33
ing,
the
department
may
impose
on
a
health
insurance
issuer,
health
benefit
34
plan,
or
utilization
review
organization
an
administrative
fine
not
to
ex
-
35
ceed
ten
thousand
dollars
($10,000)
per
violation
for
failure
to
submit
a
re
-
36
quested
plan
of
correction,
failure
to
comply
with
its
plan
of
correction,
37
or
repeated
violations
of
this
chapter.
All
fines
collected
by
the
depart
-
38
ment
pursuant
to
this
section
shall
be
deposited
in
the
state
general
fund.
39
The
department
may
also
exercise
all
authority
granted
to
it
under
the
pro
-
40
visions
of
chapter
59,
title
41,
Idaho
Code,
to
deny
or
revoke
approval
of
a
41
utilization
review
organization
for
a
violation
of
this
chapter.
42
(2)
An
enrollee
or
an
enrollee's
health
care
provider
who
has
evidence
43
that
the
enrollee's
health
insurance
issuer
or
health
benefit
plan
is
in
44
violation
of
the
provisions
of
this
chapter
may
file
a
complaint
with
the
45
department.
The
department
shall
review
all
complaints
received
and
in
-
46
vestigate
all
complaints
that
it
deems
to
state
a
potential
violation.
The
47
department
shall
fairly,
efficiently,
and
timely
review
and
investigate
48
11
complaints
and
shall
provide
the
subject
of
the
complaint
an
opportunity
to
1
refute
the
evidence
against
it.
Health
insurance
issuers,
health
benefit
2
plans,
and
utilization
review
organizations
found
to
be
in
violation
of
this
3
chapter
shall
be
penalized
in
accordance
with
this
section.
4
(3)
There
shall
be
no
private
right
of
action
under
this
chapter.
5
41
-
3517.
REPORTS
TO
THE
DEPARTMENT.
(1)
By
June
1,
2027,
and
each
June
6
1
thereafter,
a
health
insurance
issuer
shall
report
to
the
department,
on
a
7
form
issued
by
the
department,
the
following
aggregated
trend
data,
de
-
iden
-
8
tified
of
protected
health
information,
related
to
the
insurer's
practices
9
and
experience
for
the
prior
plan
year
for
health
care
services
submitted
for
10
payment:
1
1
(a)
The
number
of
prior
authorization
requests;
12
(b)
The
percentage
of
prior
authorization
requests
denied;
13
(c)
The
percentage
of
prior
authorization
appeals
received;
14
(d)
The
percentage
of
adverse
determinations
reversed
on
appeal;
15
(e)
The
percentage
of
prior
authorization
requests
that
were
not
sub
-
16
mitted
electronically;
17
(f)
As
a
percentage
by
service,
the
ten
(10)
health
care
services
that
18
were
most
frequently
denied
through
prior
authorization;
and
19
(g)
The
five
(5)
reasons
prior
authorization
requests
were
most
fre
-
20
quently
denied.
21
(2)
All
reports
required
by
this
section
shall
be
considered
public
22
records
pursuant
to
chapter
1,
title
74,
Idaho
Code,
and
the
department
shall
23
make
all
reports
freely
available
to
requesters
and
post
all
reports
to
its
24
public
website
without
redactions.
25
41
-
3518.
FALSE
REQUESTS
FOR
PRIOR
AUTHORIZATION.
If
a
health
insur
-
26
ance
issuer
has
clear
and
convincing
evidence
that
a
health
care
profes
-
27
sional
or
health
care
provider
has
knowingly
and
willfully
submitted
false
28
or
fraudulent
requests
for
prior
authorization
to
the
health
insurance
is
-
29
suer,
the
health
insurance
issuer
shall
notify
and
provide
that
information
30
to
the
department
director.
After
receipt
of
such
notification
and
infor
-
31
mation,
the
director
shall
forward
these
reports
to
the
board
of
medicine
or
32
such
other
licensing
agency
with
oversight
of
the
health
care
professional
33
or
health
care
provider
and
to
the
office
of
the
prosecuting
authority
having
34
jurisdiction.
35
41
-
3519.
DE
MINIMIS
PRIOR
AUTHORIZATION
UTILIZATION
EXEMPTION.
(1)
A
36
health
insurance
issuer
that,
for
the
prior
plan
year,
required
prior
autho
-
37
rization
for
less
than
one
percent
(1%)
of
claims
submitted
for
payment
under
38
health
benefit
plans
issued
or
delivered
in
Idaho
may
elect
to
be
exempt
from
39
the
requirements
of
this
chapter.
40
(2)
The
election
shall
be
made
by
filing
an
annual
attestation
with
the
41
department,
in
a
form
and
manner
specified
by
the
department,
demonstrating
42
that
the
health
insurance
issuer
meets
the
threshold
provided
for
in
subsec
-
43
tion
(1)
of
this
section.
44
(3)
Upon
request,
the
health
insurance
issuer
shall
provide
records
45
reasonably
necessary
for
the
department
to
verify
the
attestation
provided
46
for
in
subsection
(2)
of
this
section.
If
the
department
determines
the
47
12
health
insurance
issuer
does
not
meet
the
threshold,
the
department
may
re
-
1
voke
the
exemption
and
require
compliance
within
a
reasonable
period.
2
41
-
3520.
RULES.
The
department
shall
have
the
authority
to
promulgate
3
rules,
subject
to
legislative
approval,
pursuant
to
the
provisions
of
chap
-
4
ter
52,
title
67,
Idaho
Code,
to
govern
the
administration
of
this
chapter.
5
SECTION
2.
This
act
shall
be
in
full
force
and
effect
on
and
after
Jan
-
6
uary
1,
2027.
7