Read the full stored bill text
House
File
2412
-
Introduced
HOUSE
FILE
2412
BY
RINKER
A
BILL
FOR
An
Act
relating
to
prior
authorization
exemptions
for
certain
1
health
care
providers
for
specific
health
care
services.
2
BE
IT
ENACTED
BY
THE
GENERAL
ASSEMBLY
OF
THE
STATE
OF
IOWA:
3
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Section
1.
NEW
SECTION
.
514F.10
Prior
authorization
1
exemption
——
health
care
providers.
2
1.
Definitions.
For
purposes
of
this
section:
3
a.
“Covered
person”
means
the
same
as
defined
in
section
4
514F.8.
5
b.
“Evaluation”
means
either
of
the
following:
6
(1)
A
review
of
the
outcomes
of
preauthorization
7
requests
submitted
by
a
health
care
provider
during
the
8
most
recent
evaluation
period
to
determine
the
percentage
of
9
the
preauthorization
requests
that
were
approved,
and
that
10
is
conducted
to
determine
whether
to
grant
the
health
care
11
provider
an
exemption
for
a
specific
health
care
service
for
12
which
the
provider
does
not
have
an
exemption.
13
(2)
A
retrospective
review
of
a
random
sample
of
claims
14
submitted
by
a
health
care
provider
during
the
most
recent
15
evaluation
period
to
determine
the
percentage
of
claims
that
16
would
have
been
approved,
based
on
meeting
the
health
carrier’s
17
applicable
medical
necessity
criteria
at
the
time
the
health
18
care
service
was
provided,
and
that
is
conducted
to
determine
19
whether
to
rescind
the
health
care
provider’s
exemption,
20
consistent
with
subsection
5,
for
a
specific
health
care
21
service.
22
c.
“Evaluation
period”
means
the
three-month
period
23
immediately
preceding
an
evaluation,
including
all
of
the
24
following:
25
(1)
For
an
initial
exemption
determination,
the
evaluation
26
period
shall
be
the
three-month
period
beginning
on
January
1,
27
2027,
then
annually
for
any
consecutive
three-month
period
in
28
the
immediately
preceding
calendar
year.
29
(2)
After
an
exemption
denial
or
an
exemption
rescission
30
for
a
specific
health
care
service,
the
subsequent
three-month
31
evaluation
period
shall
begin
on
the
first
day
immediately
32
after
the
last
day
of
the
evaluation
period
that
formed
the
33
basis
for
the
exemption
denial
or
exemption
rescission.
34
(3)
For
a
retrospective
review
conducted
pursuant
to
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subsection
5,
paragraph
“a”
,
subparagraph
(2),
the
evaluation
1
period
shall
be
any
three-month
period
selected
by
the
health
2
carrier.
3
d.
“Exemption”
means
an
exception
to
a
health
carrier’s
4
requirement
that
a
health
care
provider
obtain
prior
5
authorization
for
a
specific
health
care
service.
6
e.
“Facility”
means
the
same
as
defined
in
section
514J.102.
7
f.
“Health
benefit
plan”
means
the
same
as
defined
in
8
section
514J.102.
9
g.
“Health
care
professional”
means
the
same
as
defined
in
10
514J.102.
11
h.
“Health
care
provider”
means
the
same
as
defined
in
12
section
514J.102.
13
i.
“Health
care
services”
means
the
same
as
defined
in
14
section
514J.102.
15
j.
“Health
carrier”
means
the
same
as
defined
in
section
16
514F.8.
17
k.
“Independent
review
organization”
means
an
entity
18
that
conducts
an
independent
external
review
of
an
adverse
19
determination.
20
l.
“Prior
authorization”
means
the
same
as
defined
in
21
section
514F.8.
22
m.
“Random
sample”
means
between
five
and
twenty
claims
23
for
a
specific
health
care
service
submitted
by
a
health
care
24
provider
during
the
most
recent
evaluation
period.
25
2.
Exemption.
26
a.
A
health
carrier
that
requires
prior
authorization
for
27
certain
health
care
services
shall
grant
a
health
care
provider
28
an
exemption
for
a
specific
health
care
service,
if,
in
the
29
most
recent
evaluation
period,
the
health
carrier
has
approved
30
not
less
than
ninety-five
percent
of
the
health
care
provider’s
31
prior
authorization
requests
for
the
specific
health
care
32
service.
33
b.
A
health
carrier
shall
conduct
an
annual
evaluation
34
of
each
health
care
provider
that
is
contracted
with
the
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health
carrier
to
provide
health
care
services
to
the
health
1
carrier’s
covered
persons
a
minimum
of
once
every
three
months
2
to
determine
if
the
health
care
provider
qualifies
for
an
3
exemption
under
paragraph
“a”
.
A
health
carrier
may
continue
a
4
health
care
provider’s
exemption
granted
under
paragraph
“a”
5
without
conducting
an
evaluation
for
a
specific
evaluation
6
period.
7
c.
A
health
care
provider
shall
not
be
required
to
request
8
an
exemption
from
a
health
carrier
to
qualify
for
an
exemption
9
under
paragraph
“a”
.
10
d.
No
later
than
five
calendar
days
after
a
health
care
11
provider
qualifies
for
an
exemption,
the
health
carrier
shall
12
provide
a
notice
to
the
health
care
provider
that
includes
all
13
of
the
following:
14
(1)
A
statement
that
the
health
care
provider
qualifies
for
15
an
exemption
under
paragraph
“a”
.
16
(2)
A
complete
list
of
all
health
benefit
plans
and
health
17
care
services
to
which
the
exemption
applies.
18
(3)
The
duration
of
the
exemption.
19
e.
If
a
health
care
provider
submits
a
prior
authorization
20
request
for
a
health
care
service
for
which
the
health
care
21
provider
qualifies
for
an
exemption
under
paragraph
“a”
,
22
the
health
carrier
shall
promptly
provide
the
notice
under
23
paragraph
“d”
to
the
health
care
provider
and
an
explanation
of
24
the
health
carrier’s
claim
submission
requirements.
25
3.
Duration
of
exemption.
A
health
care
provider’s
26
exemption
granted
under
subsection
2,
paragraph
“a”
,
shall
27
remain
in
effect
until
either
of
the
following
occurs:
28
a.
The
health
carrier
notifies
the
health
care
provider
29
of
the
health
carrier’s
decision
to
rescind
the
health
care
30
provider’s
exemption,
and
the
health
care
provider
fails
to
31
appeal
the
health
carrier’s
decision
within
thirty
calendar
32
days,
at
which
time
the
health
care
provider’s
exemption
shall
33
be
rescinded
effective
thirty-one
calendar
days
after
the
date
34
of
the
health
carrier’s
rescission
notice.
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b.
If
a
health
care
provider
appeals
a
health
carrier’s
1
decision
to
rescind
the
health
care
provider’s
exemption
within
2
the
thirty-day
appeal
period
and
the
decision
is
upheld
on
3
appeal,
the
health
care
provider’s
exemption
shall
be
rescinded
4
effective
five
calendar
days
after
the
date
the
rescission
5
decision
is
upheld.
6
4.
Denial
of
exemption.
A
health
carrier
may
deny
an
7
exemption
for
a
health
care
provider
for
a
specific
health
8
care
service
if
the
health
carrier
provides
the
health
care
9
provider
with
sufficient
statistics
and
documentation
for
the
10
relevant
evaluation
period
to
demonstrate
that
the
health
11
care
provider
does
not
meet
the
health
carrier’s
criteria
for
12
exemption.
The
health
carrier
shall
notify
the
health
care
13
provider
not
more
than
five
calendar
days
after
the
date
of
the
14
health
carrier’s
decision
to
deny
the
exemption.
At
the
same
15
time
as
the
notice,
the
health
carrier
must
provide
the
health
16
care
provider
with
a
plain-language
explanation
of
the
health
17
care
provider’s
right
to
an
appeal
of,
or
to
an
independent
18
review
of,
the
health
carrier’s
decision,
and
of
the
process
19
for
the
health
care
provider
to
file
an
appeal
or
to
request
an
20
independent
review.
21
5.
Rescission
of
exemption.
22
a.
A
health
carrier
may
rescind
a
health
care
provider’s
23
exemption
for
a
specific
health
care
service
granted
under
24
subsection
2,
paragraph
“a”
,
if,
during
a
retrospective
review
25
of
a
random
sample
of
the
health
care
provider’s
claims,
the
26
health
carrier
determines
that
less
than
ninety-five
percent
27
of
the
claims
for
the
specific
health
care
service
met
the
28
medical
necessity
and
appropriateness
criteria
used
by
the
29
health
carrier
for
conducting
a
prior
authorization
review
for
30
the
specific
health
care
service
during
the
relevant
evaluation
31
period.
A
determination
made
under
this
subsection
must
32
be
made
by
a
health
care
professional
licensed
to
practice
33
medicine
in
this
state.
If
a
determination
is
made
with
34
respect
to
a
health
care
professional
who
is
a
physician,
the
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determination
must
be
made
by
a
physician
licensed
in
this
1
state
who
has
either
the
same
or
a
similar
medical
specialty
as
2
the
health
care
professional.
3
b.
The
health
carrier
must
notify
the
health
care
provider
4
not
less
than
thirty
calendar
days
before
the
date
that
the
5
rescission
is
effective.
At
the
same
time
as
the
notice,
the
6
health
carrier
must
provide
the
health
care
provider
with
all
7
of
the
following:
8
(1)
Sufficient
statistics
and
documentation
from
the
9
health
carrier’s
retrospective
review
under
paragraph
“a”
,
10
subparagraph
(2),
to
substantiate
the
health
carrier’s
decision
11
to
rescind
the
health
care
provider’s
exemption.
12
(2)
A
plain-language
explanation
of
the
health
care
13
provider’s
right
to
an
appeal
of,
or
to
an
independent
review
14
of,
the
health
carrier’s
decision
to
rescind
the
health
care
15
provider’s
exemption,
and
of
the
process
for
the
health
care
16
provider
to
file
an
appeal
or
to
request
an
independent
review.
17
6.
Appeal
or
independent
review.
18
a.
A
health
care
provider
shall
have
the
right
to
appeal
an
19
adverse
exemption
determination,
and
have
the
right
to
a
review
20
of
the
determination
by
an
independent
review
organization.
21
A
health
carrier
shall
not
require
a
health
care
provider
to
22
participate
in
the
health
carrier’s
internal
appeal
process
23
prior
to
requesting
an
independent
review.
24
b.
The
health
carrier
shall
pay
the
cost
of
an
appeal
25
and
the
cost
of
an
independent
review
requested
by
a
health
26
care
provider
under
this
subsection.
The
costs
shall
include
27
reasonable
fees
for
copies
of
applicable
medical
records
or
28
other
documents
requested
from
the
health
care
provider
during
29
the
internal
appeal
or
the
independent
review.
30
c.
(1)
An
independent
review
organization
shall
complete
an
31
independent
review
requested
by
a
health
care
provider
under
32
this
section
no
later
than
thirty
calendar
days
after
the
date
33
of
the
health
care
provider’s
request.
34
(2)
A
health
care
provider
may
request
that
the
independent
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review
organization
evaluate
an
additional
random
sample
from
1
the
relevant
evaluation
period
as
part
of
the
independent
2
review
organization’s
review.
If
the
health
care
provider
3
requests
that
the
independent
review
organization
evaluate
an
4
additional
random
sample,
the
independent
review
organization
5
shall
base
its
determination
on
the
medical
necessity
and
6
appropriateness
of
both
the
random
samples
reviewed
under
7
subsection
5,
paragraph
“a”
,
subparagraph
(2),
and
the
random
8
samples
reviewed
under
this
subparagraph.
9
d.
The
health
carrier
and
the
health
care
provider
shall
10
be
bound
by
the
appeal
decision
or
by
the
independent
review
11
organization’s
determination.
12
e.
If
a
health
carrier’s
adverse
exemption
determination
is
13
overturned
on
appeal
or
by
an
independent
review
organization,
14
the
health
carrier
shall
not
attempt
to
rescind
the
health
care
15
provider’s
exemption
prior
to
the
end
of
the
next-occurring
16
evaluation
period.
After
the
date
on
which
the
next-occurring
17
evaluation
period
ends,
the
health
carrier
may
rescind
the
18
health
care
provider’s
exemption
if
the
health
carrier
complies
19
with
subsection
5
and
this
subsection.
20
f.
A
health
carrier
shall
not
retroactively
deny
a
health
21
care
service
for
a
covered
person
on
the
basis
of
the
health
22
carrier’s
rescission
of
the
health
care
provider’s
exemption,
23
even
if
the
health
carrier’s
rescission
decision
is
affirmed
on
24
appeal
or
by
an
independent
review
organization.
25
7.
Exemption
eligibility
after
rescission
or
denial.
If
26
an
appeal
or
an
independent
review
organization
affirms
a
27
rescission
or
a
denial
of
a
health
care
provider’s
exemption
28
for
a
specific
health
care
service,
the
health
care
provider
29
shall
be
eligible
for
an
exemption
for
the
same
health
care
30
service
after
the
last
day
of
the
three-month
evaluation
period
31
immediately
following
the
evaluation
period
that
was
the
basis
32
for
the
denial
or
rescission.
33
8.
Effect
of
exemption.
34
a.
A
health
carrier
shall
not
deny
or
reduce
payment
on
a
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health
care
provider’s
claim
based
on
the
medical
necessity
or
1
medical
appropriateness
of
care
for
a
health
care
service
for
2
which
the
health
care
provider
qualified
for
an
exemption
under
3
subsection
2,
unless
the
health
care
provider
knowingly
and
4
materially
misrepresented
the
health
care
service
in
the
claim
5
with
the
specific
intent
to
deceive
the
health
carrier
and
to
6
obtain
an
unlawful
claim
payment.
7
b.
A
health
carrier
shall
not
conduct
a
retrospective
review
8
of
a
health
care
service
provided
by
a
health
care
provider
who
9
has
been
allowed
an
exemption
for
the
health
care
service
under
10
subsection
2,
except
in
the
following
circumstances:
11
(1)
Pursuant
to
subsection
5,
paragraph
“a”
,
subparagraph
12
(2).
13
(2)
The
health
carrier
has
reasonable
cause
to
suspect
a
14
basis
for
denial
of
a
claim
under
paragraph
“a”
.
15
9.
Scope
of
practice.
This
section
shall
not
be
construed
16
to
permit
a
health
care
provider
to
provide
a
health
care
17
service
outside
the
scope
of
the
health
care
provider’s
18
license,
or
to
require
a
health
carrier
to
pay
a
claim
19
submitted
by
a
health
care
provider
for
a
health
care
service
20
outside
the
scope
of
the
health
care
provider’s
license.
21
10.
Applicability.
This
section
applies
to
all
health
22
benefit
plans
delivered,
issued
for
delivery,
continued,
or
23
renewed
in
this
state
on
or
after
January
1,
2027.
24
EXPLANATION
25
The
inclusion
of
this
explanation
does
not
constitute
agreement
with
26
the
explanation’s
substance
by
the
members
of
the
general
assembly.
27
This
bill
relates
to
prior
authorization
exemptions
for
28
certain
health
care
providers
for
certain
health
care
services.
29
The
bill
requires
health
carriers
(carrier)
that
require
30
prior
authorization
for
certain
health
care
services
(services)
31
to
grant
a
health
care
provider
(provider)
an
exemption,
32
if,
in
the
most
recent
evaluation
period
(period),
the
33
carrier
has
approved
not
less
than
95
percent
of
the
prior
34
authorization
requests
submitted
by
that
provider
for
the
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specific
service.
“Exemption”
is
defined
in
the
bill
as
an
1
exception
to
a
carrier’s
requirement
that
a
provider
obtain
2
prior
authorization
for
a
specific
service.
“Evaluation
3
period”
is
defined
in
the
bill.
4
A
carrier
shall
conduct
an
evaluation
of
each
provider
5
that
is
contracted
with
the
carrier
to
provide
services
to
6
the
carrier’s
covered
persons
a
minimum
of
once
every
three
7
months
to
determine
if
the
provider
qualifies
for
an
exemption.
8
“Evaluation”
is
defined
in
the
bill.
A
carrier
may
continue
9
an
exemption
without
conducting
an
evaluation
for
a
specific
10
evaluation
period.
A
provider
is
not
required
to
request
11
a
provider’s
exemption
from
a
carrier
to
qualify
for
an
12
exemption.
No
later
than
five
calendar
days
after
a
provider
13
qualifies
for
an
exemption,
the
carrier
shall
provide
a
notice
14
to
the
provider
that
includes
a
statement
that
the
provider
15
qualifies
for
an
exemption,
a
complete
list
of
all
health
16
benefit
plans
and
services
to
which
the
exemption
applies,
and
17
the
duration
of
the
exemption.
If
a
provider
submits
a
prior
18
authorization
request
for
a
service
for
which
the
provider
19
qualifies
for
an
exemption,
the
carrier
shall
promptly
provide
20
the
provider
with
the
same
notice.
21
If
a
carrier
notifies
a
provider
of
the
carrier’s
decision
22
to
rescind
the
provider’s
exemption
and
the
provider
fails
to
23
appeal
the
decision
within
30
calendar
days,
the
provider’s
24
exemption
is
rescinded
effective
31
calendar
days
after
the
25
date
of
the
carrier’s
notice.
If
the
provider
appeals
the
26
carrier’s
decision
within
the
30-day
appeal
period
and
the
27
decision
is
upheld
on
appeal,
the
provider’s
exemption
shall
28
be
rescinded
five
calendar
days
after
the
date
the
decision
is
29
upheld.
30
A
carrier
may
deny
an
exemption
for
a
provider
for
a
31
specific
service
if
the
carrier
provides
the
provider
with
32
sufficient
statistics
and
documentation
for
the
relevant
33
period
to
demonstrate
that
the
provider
does
not
meet
the
34
carrier’s
criteria
for
exemption.
The
carrier
must
satisfy
the
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notification
requirements
detailed
in
the
bill.
1
A
carrier
may
rescind
a
provider’s
exemption
if
a
2
retrospective
review
of
a
random
sample
of
the
provider’s
3
claims
show
that
less
than
95
percent
of
the
claims
4
for
the
specific
service
met
the
medical
necessity
and
5
appropriateness
criteria
used
by
the
carrier
for
conducting
6
a
prior
authorization
review
for
the
specific
service
7
during
the
relevant
period.
“Random
sample”
is
defined
in
8
the
bill.
The
determination
must
be
made
by
a
health
care
9
professional
licensed
to
practice
medicine
in
this
state,
and
10
if
the
determination
is
made
with
respect
to
a
health
care
11
professional
who
is
a
physician,
the
determination
must
be
made
12
by
a
physician
licensed
in
this
state
who
has
either
the
same
13
or
a
similar
medical
specialty
as
the
health
care
professional.
14
The
carrier
must
notify
the
provider
not
less
than
30
days
15
before
the
date
the
rescission
is
effective.
The
carrier
must
16
provide
the
provider
with
documentation,
as
detailed
in
the
17
bill,
with
the
notice.
18
A
provider
shall
have
the
right
to
appeal
an
adverse
19
exemption
determination
as
detailed
in
the
bill,
and
the
20
carrier
and
provider
are
bound
by
the
appeal
decision
or
the
21
independent
review
organization’s
(organization)
determination.
22
If
a
carrier’s
adverse
exemption
determination
is
overturned
23
by
an
organization,
the
carrier
shall
not
attempt
to
rescind
24
the
provider’s
exemption
prior
to
the
end
of
the
next
occurring
25
period.
A
carrier
shall
not
retroactively
deny
a
service
26
on
the
basis
of
the
carrier’s
rescission
of
the
provider’s
27
exemption,
even
if
the
carrier’s
decision
is
affirmed
on
appeal
28
or
by
an
organization’s
determination.
If
an
appeal
or
an
29
organization’s
determination
affirms
the
rescission
or
denial
30
of
a
provider’s
exemption
for
a
specific
service,
the
provider
31
shall
be
eligible
for
an
exemption
for
the
same
service
after
32
the
last
day
of
the
three-month
period
immediately
following
33
the
period
that
was
the
basis
for
the
denial
or
rescission.
34
A
carrier
shall
not
deny
or
reduce
payment
on
a
provider’s
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claim
based
on
the
medical
necessity
or
appropriateness
1
of
care
for
a
service
for
which
the
provider
qualified
for
2
an
exemption,
unless
the
provider
knowingly
and
materially
3
misrepresented
the
service
in
the
claim
with
the
specific
4
intent
to
deceive
the
carrier
and
to
obtain
an
unlawful
5
claim
payment
on
the
claim.
A
carrier
shall
not
conduct
a
6
retrospective
review
of
a
service
provided
by
a
provider
who
7
has
been
granted
an
exemption
for
the
service
except
in
the
8
circumstances
detailed
in
the
bill.
9
The
bill
shall
not
be
construed
to
permit
a
provider
to
10
provide
a
service
outside
the
scope
of
the
provider’s
license,
11
or
to
require
a
carrier
to
pay
a
claim
submitted
by
a
provider
12
for
a
service
outside
the
scope
of
the
provider’s
license.
13
The
bill
applies
to
all
health
benefit
plans
delivered,
14
issued
for
delivery,
continued,
or
renewed
in
this
state
on
or
15
after
January
1,
2027.
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