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House
File
2438
-
Introduced
HOUSE
FILE
2438
BY
HARRIS
and
YOUNG
A
BILL
FOR
An
Act
relating
to
health
carriers
and
payment
of
claims,
1
audits,
and
standards
of
conduct;
prior
authorizations
2
and
utilization
review
organizations;
and
providing
civil
3
penalties
and
including
applicability
provisions.
4
BE
IT
ENACTED
BY
THE
GENERAL
ASSEMBLY
OF
THE
STATE
OF
IOWA:
5
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DIVISION
I
1
HEALTH
INSURANCE
TRADE
PRACTICES
2
Section
1.
Section
507B.4,
subsection
3,
paragraph
j,
3
subparagraph
(15),
Code
2026,
is
amended
to
read
as
follows:
4
(15)
Failing
to
comply
with
the
procedures
for
auditing
5
claims
submitted
by
health
care
providers
as
set
forth
in
6
section
507B.15
or
as
otherwise
provided
by
rule
of
the
7
commissioner.
However,
this
subparagraph
shall
have
no
8
applicability
to
liability
insurance,
workers’
compensation
or
9
similar
insurance,
automobile
or
homeowners’
medical
payment
10
insurance,
disability
income,
or
long-term
care
insurance.
11
Sec.
2.
Section
507B.4,
subsection
3,
Code
2026,
is
amended
12
by
adding
the
following
new
paragraphs:
13
NEW
PARAGRAPH
.
w.
Standards
of
conduct.
Any
violation
of
14
section
507B.16
by
a
health
carrier.
15
NEW
PARAGRAPH
.
x.
Prior
authorization
——
peer
review.
Any
16
violation
of
section
514F.8A
by
a
utilization
review
17
organization
or
a
health
carrier.
18
Sec.
3.
Section
507B.4A,
subsection
2,
paragraph
a,
Code
19
2026,
is
amended
by
striking
the
paragraph
and
inserting
in
20
lieu
thereof
the
following:
21
a.
An
insurer
shall
comply
with
all
of
the
following:
22
(1)
An
insurer
shall
either
accept
and
pay
or
deny
a
clean
23
claim
no
later
than
thirty
calendar
days
after
the
date
the
24
insurer
receives
an
electronic
claim
submission,
or
no
later
25
than
forty-five
calendar
days
after
the
date
the
insurer
26
receives
a
claim
submitted
on
paper.
27
(2)
After
the
date
of
payment
of
a
clean
claim,
an
insurer
28
shall
not
retroactively
deny,
reduce,
or
recoup
payment
of
the
29
claim
unless
the
insurer
first
provides
written
notice
and
30
evidence
of
any
of
the
following
to
the
health
care
provider
31
that
submitted
the
claim:
32
(a)
The
claim
submission
included
a
misrepresentation.
33
(b)
The
claim
submission
was
fraudulent.
34
(c)
The
claim
submission
was
a
duplicate
submission
of
a
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claim
for
which
the
insurer
previously
paid.
1
Sec.
4.
Section
507B.4A,
subsection
2,
Code
2026,
is
amended
2
by
adding
the
following
new
paragraph:
3
NEW
PARAGRAPH
.
0c.
For
purposes
of
this
subsection,
4
“insurer”
includes
all
of
the
following:
5
(1)
An
insurer
providing
accident
and
sickness
insurance
6
under
chapter
509,
514,
or
514A;
a
health
maintenance
7
organization;
or
another
entity
providing
health
insurance
or
8
health
benefits
subject
to
state
insurance
regulation.
9
(2)
The
medical
assistance
program
under
chapter
249A
and
10
the
healthy
and
well
kids
in
Iowa
(Hawki)
program
under
chapter
11
514I.
12
(3)
A
managed
care
organization
acting
pursuant
to
a
13
contract
with
the
department
of
health
and
human
services
to
14
administer
the
medical
assistance
program
under
chapter
249A,
15
or
the
healthy
and
well
kids
in
Iowa
(Hawki)
program
under
16
chapter
514I.
17
Sec.
5.
NEW
SECTION
.
507B.15
Health
carriers
——
audits
and
18
claim
submissions.
19
1.
As
used
in
this
section,
unless
the
context
otherwise
20
requires:
21
a.
“Audit”
means
a
review,
investigation,
or
request
for
22
additional
documentation
by
a
health
carrier
before
or
after
23
issuing
payment
on
a
clean
claim
to
a
health
care
provider.
24
b.
“Clean
claim”
means
a
properly
completed
paper
or
25
electronic
billing
instrument
containing
all
reasonably
26
necessary
information
that
does
not
involve
coordination
of
27
benefits
for
third-party
liability,
preexisting
condition
28
investigations,
or
subrogation,
and
that
does
not
involve
29
the
existence
of
particular
circumstances
requiring
special
30
treatment
that
prevents
a
prompt
payment
from
being
made.
31
c.
“Health
care
provider”
means
the
same
as
defined
in
32
section
514J.102.
33
d.
“Health
carrier”
means
an
entity
subject
to
the
34
insurance
laws
and
regulations
of
this
state,
or
subject
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to
the
jurisdiction
of
the
commissioner,
including
an
1
insurance
company
offering
sickness
and
accident
plans,
a
2
health
maintenance
organization,
a
nonprofit
health
service
3
corporation,
a
plan
established
pursuant
to
chapter
509A
4
for
public
employees,
or
any
other
entity
providing
a
plan
5
of
health
insurance,
health
care
benefits,
or
health
care
6
services.
“Health
carrier”
includes
the
following:
7
(1)
The
medical
assistance
program
under
chapter
249A
and
8
the
healthy
and
well
kids
in
Iowa
(Hawki)
program
under
chapter
9
514I.
10
(2)
A
managed
care
organization
acting
pursuant
to
a
11
contract
with
the
department
of
health
and
human
services
to
12
administer
the
medical
assistance
program
under
chapter
249A,
13
or
the
healthy
and
well
kids
in
Iowa
(Hawki)
program
under
14
chapter
514I.
15
2.
If
a
health
carrier
conducts
an
audit
of
a
clean
claim
16
submitted
by
a
health
care
provider,
the
health
carrier
17
shall
reimburse
the
health
care
provider
for
the
reasonable
18
administrative
costs
incurred
and
documented
by
the
health
care
19
provider
to
respond
to
the
audit,
including
but
not
limited
to
20
staff
time,
copying,
and
record
retrieval.
21
3.
a.
A
health
carrier
that
conducts
an
audit
shall
notify
22
the
health
care
provider
that
submitted
the
clean
claim
of
the
23
initiation
of
the
audit
no
later
than
fifteen
calendar
days
24
after
the
date
the
health
carrier
selects
the
clean
claim
for
25
audit.
26
b.
A
health
carrier
shall
complete
an
audit
of
a
clean
claim
27
and
issue
a
determination
on
the
clean
claim
to
the
health
28
care
provider
that
submitted
the
clean
claim
no
later
than
29
forty-five
calendar
days
after
the
date
that
the
health
carrier
30
receives
all
requested
documentation
regarding
the
clean
claim
31
from
the
health
care
provider.
32
c.
A
health
care
provider
that
submitted
a
clean
claim
33
that
is
the
subject
of
an
audit
by
a
health
carrier,
and
that
34
receives
an
adverse
determination
regarding
the
clean
claim,
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may
appeal
the
adverse
determination
no
later
than
thirty
1
calendar
days
after
the
date
the
health
care
provider
receives
2
the
audit
determination.
3
d.
A
health
carrier
shall
consider
an
appeal
under
4
subparagraph
“c”
,
and
issue
a
final
determination
on
the
clean
5
claim
that
is
the
subject
of
the
appeal,
no
later
than
fourteen
6
calendar
days
after
the
date
the
health
carrier
receives
notice
7
of
the
appeal.
8
e.
If
a
health
carrier
violates
this
subsection,
the
clean
9
claim
shall
be
automatically
approved
by
the
health
carrier
and
10
promptly
paid,
including
interest
at
the
rate
of
ten
percent
11
per
annum.
12
4.
a.
A
violation
of
this
section
by
a
health
carrier
13
shall
constitute
an
unfair
method
of
competition
or
unfair
or
14
deceptive
act
or
practice
under
section
507B.4.
15
b.
A
health
carrier
that
violates
this
section
shall
be
16
subject
to
civil
penalties
under
section
505.7A.
17
c.
In
any
action
brought
by
a
health
care
provider
for
a
18
violation
of
this
section,
the
health
care
provider
shall
be
19
entitled
to
recover
costs
of
litigation,
including
reasonable
20
attorney
fees
and
other
litigation
expenses
incurred
by
the
21
health
care
provider,
regardless
of
whether
the
health
care
22
provider
prevails
in
such
action.
23
5.
The
commissioner
shall
adopt
rules
pursuant
to
chapter
24
17A
to
administer
and
enforce
this
section.
25
6.
a.
This
section
shall
not
apply
to
a
claim
that
is
under
26
active
fraud
investigation
by
a
state
or
federal
authority.
27
b.
This
section
shall
not
apply
to
a
federal
program
where
28
audits
are
mandated
by
federal
law.
29
Sec.
6.
NEW
SECTION
.
507B.16
Health
carriers
——
standards
30
of
conduct.
31
1.
As
used
in
this
section:
32
a.
“Health
care
provider”
means
the
same
as
defined
in
33
section
514J.102.
34
b.
“Health
carrier”
means
an
entity
subject
to
the
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insurance
laws
and
regulations
of
this
state,
or
subject
1
to
the
jurisdiction
of
the
commissioner,
including
an
2
insurance
company
offering
sickness
and
accident
plans,
a
3
health
maintenance
organization,
a
nonprofit
health
service
4
corporation,
a
plan
established
pursuant
to
chapter
509A
5
for
public
employees,
or
any
other
entity
providing
a
plan
6
of
health
insurance,
health
care
benefits,
or
health
care
7
services.
“Health
carrier”
includes
the
following:
8
(1)
The
medical
assistance
program
under
chapter
249A
and
9
the
healthy
and
well
kids
in
Iowa
(Hawki)
program
under
chapter
10
514I.
11
(2)
A
managed
care
organization
acting
pursuant
to
a
12
contract
with
the
department
of
health
and
human
services
to
13
administer
the
medical
assistance
program
under
chapter
249A,
14
or
the
healthy
and
well
kids
in
Iowa
(Hawki)
program
under
15
chapter
514I.
16
2.
A
health
carrier
shall
not
impose
on
a
health
care
17
provider,
directly
or
indirectly,
any
financial
penalty,
18
reimbursement
reduction,
or
administrative
fee,
or
terminate
a
19
health
care
provider’s
participation
in
the
health
carrier’s
20
network,
based
on
the
health
care
provider’s
referral
to,
or
21
affiliation
with,
an
out-of-network
health
care
provider.
22
3.
A
health
carrier
shall
not
interfere
with,
or
participate
23
in
any
capacity
in,
a
health
care
provider’s
decisions
24
regarding
staffing
and
referral,
except
as
otherwise
provided
25
by
law.
26
4.
A
health
carrier
shall
not
offer,
attempt
to
enforce,
27
or
enforce
an
agreement,
or
an
amendment
to
an
agreement,
with
28
a
health
care
provider
without
providing
an
opportunity
for
29
negotiation.
A
contract
term
that
imposes
an
unreasonable
or
30
unconscionable
obligation
on
a
health
care
provider
shall
be
31
void
and
unenforceable.
32
5.
a.
A
violation
of
this
section
by
a
health
carrier
33
shall
constitute
an
unfair
method
of
competition
or
unfair
or
34
deceptive
act
or
practice
under
section
507B.4.
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b.
A
health
carrier
that
violates
this
section
shall
be
1
subject
to
civil
penalties
according
to
section
505.7A.
2
c.
In
any
action
brought
by
a
health
care
provider
against
3
a
health
carrier
for
a
violation
of
this
section,
the
health
4
care
provider
shall
be
entitled
to
recover
costs
of
litigation,
5
including
reasonable
attorney
fees
and
other
expenses
incurred
6
by
the
health
care
provider
in
the
course
of
the
litigation,
7
regardless
of
whether
the
health
care
provider
prevails
in
such
8
action.
9
6.
The
commissioner
shall
adopt
rules
pursuant
to
chapter
10
17A
to
administer
and
enforce
this
section.
11
DIVISION
II
12
PRIOR
AUTHORIZATIONS
13
Sec.
7.
NEW
SECTION
.
514F.8A
Prior
authorizations
——
peer
14
review.
15
1.
For
purposes
of
this
section:
16
a.
“Clinical
peer”
means
a
health
care
professional
that
17
meets
all
of
the
following
requirements:
18
(1)
The
health
care
professional
practices
in
the
same
or
19
similar
specialty
as
the
health
care
provider
that
requested
20
a
prior
authorization.
21
(2)
The
health
care
professional
has
experience
managing
22
the
specific
medical
condition
or
administering
the
health
care
23
service
that
is
the
subject
of
the
prior
authorization
request.
24
(3)
The
health
care
professional
is
employed
by
or
25
contracted
with
the
utilization
review
organization
or
health
26
carrier
to
which
a
health
care
provider
submitted
a
request
for
27
prior
authorization.
28
b.
“Covered
person”
means
the
same
as
defined
in
section
29
514F.8.
30
c.
“Downgrade”
means
a
decision
by
a
health
carrier
31
or
utilization
review
organization
to
change
an
expedited
32
or
urgent
request
for
prior
authorization
to
a
standard
33
determination,
or
otherwise
modify
a
health
care
service
that
34
is
the
subject
of
a
request
for
prior
authorization
to
a
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lower-level
health
care
service.
1
d.
“Health
care
professional”
means
the
same
as
defined
in
2
section
514J.102.
3
e.
“Health
care
provider”
means
the
same
as
defined
in
4
section
514F.8.
5
f.
“Health
care
services”
means
the
same
as
defined
in
6
section
514F.8.
7
g.
“Health
carrier”
means
an
entity
subject
to
the
8
insurance
laws
and
regulations
of
this
state,
or
subject
9
to
the
jurisdiction
of
the
commissioner,
including
an
10
insurance
company
offering
sickness
and
accident
plans,
a
11
health
maintenance
organization,
a
nonprofit
health
service
12
corporation,
a
plan
established
pursuant
to
chapter
509A
13
for
public
employees,
or
any
other
entity
providing
a
plan
14
of
health
insurance,
health
care
benefits,
or
health
care
15
services.
“Health
carrier”
includes
the
following:
16
(1)
The
medical
assistance
program
under
chapter
249A
and
17
the
healthy
and
well
kids
in
Iowa
(Hawki)
program
under
chapter
18
514I.
19
(2)
A
managed
care
organization
acting
pursuant
to
a
20
contract
with
the
department
of
health
and
human
services
to
21
administer
the
medical
assistance
program
under
chapter
249A,
22
or
the
healthy
and
well
kids
in
Iowa
(Hawki)
program
under
23
chapter
514I.
24
h.
“Physician”
means
a
doctor
of
medicine
and
surgery,
or
a
25
doctor
of
osteopathic
medicine
and
surgery,
licensed
in
this
26
state.
27
i.
“Prior
authorization”
means
the
same
as
defined
in
28
section
514F.8.
29
j.
“Qualified
reviewer”
means
a
physician
that
meets
all
of
30
the
following
requirements:
31
(1)
The
physician
practices
in
the
same
or
a
similar
32
specialty
as
the
health
care
provider
that
requested
a
prior
33
authorization.
34
(2)
The
physician
has
the
training
and
expertise
to
treat
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the
specific
medical
condition
that
is
the
subject
of
a
1
request
for
prior
authorization,
including
sufficient
knowledge
2
to
determine
whether
the
health
care
service
that
is
the
3
subject
of
the
request
is
medically
necessary
or
clinically
4
appropriate.
5
(3)
The
physician
is
employed
by
or
contracted
with
6
the
utilization
review
organization
or
health
carrier
to
7
which
a
health
care
provider
submitted
a
request
for
prior
8
authorization.
9
k.
“Utilization
review
organization”
means
the
same
as
10
defined
in
section
514F.8.
11
2.
A
utilization
review
organization
shall
not
deny
or
12
downgrade
a
request
for
prior
authorization
unless
all
of
the
13
following
requirements
are
met:
14
a.
The
decision
to
deny
or
downgrade
the
request
is
made
by
15
either
of
the
following:
16
(1)
A
qualified
reviewer,
if
the
health
care
provider
17
requesting
prior
authorization
is
a
physician.
18
(2)
A
clinical
peer,
if
the
health
care
provider
requesting
19
prior
authorization
is
not
a
physician.
20
b.
The
utilization
review
organization
provides
the
health
21
care
provider
that
requested
the
prior
authorization
all
of
the
22
following:
23
(1)
A
written
statement
that
cites
the
specific
reasons
24
for
the
denial
or
downgrade,
including
any
coverage
criteria
25
or
limits,
or
clinical
criteria,
that
the
utilization
review
26
organization
considered
or
that
was
the
basis
for
the
denial
27
or
downgrade.
The
written
statement
shall
be
signed
by
either
28
of
the
following:
29
(a)
The
qualified
reviewer
that
made
the
denial
or
downgrade
30
determination,
if
the
health
care
provider
that
requested
prior
31
authorization
is
a
physician.
32
(b)
The
clinical
peer
that
made
the
denial
or
downgrade
33
determination,
if
the
health
care
provider
that
requested
prior
34
authorization
is
not
a
physician.
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(2)
A
written
explanation
of
the
utilization
review
1
organization’s
appeals
process.
The
utilization
review
2
organization
shall
also
provide
the
written
explanation
to
the
3
covered
person
for
whom
prior
authorization
was
requested.
4
(3)
A
written
attestation
that
is
either
of
the
following:
5
(a)
If
the
health
care
provider
that
requested
prior
6
authorization
is
a
physician,
a
written
attestation
that
7
the
qualified
reviewer
who
made
the
denial
or
downgrade
8
determination
practices
in
the
same
or
a
similar
specialty
as
9
the
health
care
provider,
and
has
the
requisite
training
and
10
expertise
to
treat
the
medical
condition
that
is
the
subject
11
of
the
request
for
prior
authorization,
including
sufficient
12
knowledge
to
determine
whether
the
health
care
service
is
13
medically
necessary
or
clinically
appropriate.
The
attestation
14
shall
include
the
qualified
reviewer’s
name,
national
provider
15
identifier,
state
medical
license
number,
board
certifications,
16
specialty
expertise,
and
educational
background.
17
(b)
If
the
health
care
provider
that
requested
prior
18
authorization
is
not
a
physician,
a
written
attestation
19
that
the
clinical
peer
who
made
the
denial
or
downgrade
20
determination
practices
in
the
same
or
a
similar
specialty
as
21
the
health
care
provider,
and
the
clinical
peer
has
experience
22
managing
the
specific
medical
condition
or
administering
23
the
health
care
service
that
is
the
subject
of
the
request
24
for
prior
authorization.
The
attestation
shall
include
the
25
clinical
peer’s
name,
national
provider
identifier,
state
26
medical
license
number,
board
certifications,
specialty
27
expertise,
and
educational
background.
28
3.
At
the
request
of
the
requesting
health
care
provider,
a
29
utilization
review
organization
that
denies
a
request
for
prior
30
authorization
shall,
no
later
than
seven
business
days
after
31
the
date
that
the
utilization
review
organization
notifies
32
the
requesting
health
care
provider
of
the
denial,
conduct
a
33
consultation
either
in
person
or
remotely,
as
follows:
34
a.
Between
the
health
care
provider
and
a
qualified
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reviewer,
if
the
health
care
provider
requesting
prior
1
authorization
is
a
physician.
2
b.
Between
the
health
care
provider
and
a
clinical
peer,
if
3
the
health
care
provider
requesting
prior
authorization
is
not
4
a
physician.
5
4.
a.
If
a
utilization
review
organization’s
decision
to
6
deny
or
downgrade
a
request
for
prior
authorization
is
appealed
7
by
the
requesting
health
care
provider
or
covered
person,
the
8
appeal
shall
be
conducted
by
either
of
the
following:
9
(1)
A
qualified
reviewer,
if
the
health
care
provider
10
requesting
prior
authorization
is
a
physician.
11
(2)
A
clinical
peer,
if
the
health
care
provider
requesting
12
prior
authorization
is
not
a
physician.
13
b.
A
qualified
reviewer
or
clinical
peer
involved
in
the
14
initial
denial
or
downgrade
determination
of
a
request
for
15
prior
authorization
that
is
the
subject
of
an
appeal
shall
not
16
conduct
the
appeal.
17
c.
When
conducting
an
appeal
of
a
request
for
prior
18
authorization,
the
qualified
reviewer
or
clinical
peer
shall
19
consider
the
known
clinical
aspects
of
the
health
care
services
20
under
review,
including
but
not
limited
to
medical
records
21
relevant
to
the
covered
person’s
medical
condition
that
22
is
the
subject
of
the
health
care
services
for
which
prior
23
authorization
is
requested,
and
any
relevant
medical
literature
24
submitted
by
the
health
care
provider
as
part
of
the
appeal.
25
5.
a.
A
violation
of
this
section
by
a
utilization
review
26
organization
or
a
health
carrier
shall
constitute
an
unfair
27
method
of
competition
or
unfair
or
deceptive
act
or
practice
28
under
section
507B.4.
29
b.
A
utilization
review
organization
or
a
health
carrier
30
that
violates
this
section
shall
be
subject
to
civil
penalties
31
according
to
section
505.7A.
32
c.
In
any
action
brought
by
a
health
care
provider
against
33
a
utilization
review
organization
or
a
health
carrier
for
a
34
violation
of
this
section,
the
health
care
provider
shall
be
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entitled
to
recover
costs
of
litigation,
including
reasonable
1
attorney
fees
and
other
expenses
incurred
by
the
health
care
2
provider
in
the
course
of
the
litigation,
regardless
of
whether
3
the
health
care
provider
prevails
in
such
action.
4
6.
The
commissioner
of
insurance
may
adopt
rules
pursuant
to
5
chapter
17A
to
administer
this
section.
6
Sec.
8.
NEW
SECTION
.
514F.8B
Prior
authorizations
——
7
exemptions.
8
1.
For
purposes
of
this
section:
9
a.
“Covered
person”
means
the
same
as
defined
in
section
10
514F.8.
11
b.
“Health
benefit
plan”
means
the
same
as
defined
in
12
section
514J.102.
13
c.
“Health
care
professional”
means
the
same
as
defined
in
14
section
514J.102.
15
d.
“Health
carrier”
means
an
entity
subject
to
the
16
insurance
laws
and
regulations
of
this
state,
or
subject
17
to
the
jurisdiction
of
the
commissioner,
including
an
18
insurance
company
offering
sickness
and
accident
plans,
a
19
health
maintenance
organization,
a
nonprofit
health
service
20
corporation,
a
plan
established
pursuant
to
chapter
509A
21
for
public
employees,
or
any
other
entity
providing
a
plan
22
of
health
insurance,
health
care
benefits,
or
health
care
23
services.
“Health
carrier”
includes
the
following:
24
(1)
The
medical
assistance
program
under
chapter
249A
and
25
the
healthy
and
well
kids
in
Iowa
(Hawki)
program
under
chapter
26
514I.
27
(2)
A
managed
care
organization
acting
pursuant
to
a
28
contract
with
the
department
of
health
and
human
services
to
29
administer
the
medical
assistance
program
under
chapter
249A,
30
or
the
healthy
and
well
kids
in
Iowa
(Hawki)
program
under
31
chapter
514I.
32
e.
“Prior
authorization”
means
the
same
as
defined
in
33
section
514F.8.
34
f.
“Utilization
review”
means
the
same
as
defined
in
section
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514F.4,
subsection
3.
1
2.
A
health
carrier
shall
not
require
prior
authorization
2
for,
or
impose
additional
utilization
review
requirements
on,
a
3
covered
person
for
any
of
the
following:
4
a.
A
cancer-related
screening
or
cancer-related
preventative
5
health
care
service
if
the
cancer-related
screening
or
6
cancer-related
service
is
recommended
by
the
covered
person’s
7
health
care
professional
based
on
the
most
recently
updated
8
national
comprehensive
cancer
network
clinical
practice
9
guidelines
in
oncology.
10
b.
Diagnosis
and
treatment
of
a
health
condition
that
11
develops
or
becomes
evident
in
a
covered
person
while
the
12
covered
person
is
receiving
treatment
at
an
inpatient
facility,
13
and
the
health
condition
is
reasonably
determined
by
a
health
14
care
professional
to
be
a
life
threatening
condition
unless
the
15
covered
person
receives
immediate
assessment
and
treatment.
16
3.
The
commissioner
of
insurance
may
adopt
rules
pursuant
to
17
chapter
17A
to
administer
this
section.
18
Sec.
9.
APPLICABILITY.
This
division
of
this
Act
applies
19
to
all
of
the
following:
20
1.
Health
benefit
plans
delivered,
issued
for
delivery,
21
continued,
or
renewed
in
this
state
on
or
after
January
1,
22
2027.
23
2.
Requests
for
prior
authorization
for
a
health
care
24
service,
if
the
request
is
made
before
January
1,
2027,
and
the
25
request
has
not
been
finally
determined
on
or
before
that
date.
26
EXPLANATION
27
The
inclusion
of
this
explanation
does
not
constitute
agreement
with
28
the
explanation’s
substance
by
the
members
of
the
general
assembly.
29
This
bill
relates
to
health
carriers
and
payment
of
claims,
30
audits,
and
standards
of
conduct,
prior
authorizations,
and
31
utilization
review
organizations.
32
DIVISION
I
——
HEALTH
INSURANCE
TRADE
PRACTICES.
Under
33
current
law,
an
insurer
shall
either
accept
and
pay
or
deny
34
a
clean
claim.
Under
the
bill,
an
insurer
shall
either
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accept
and
pay
or
deny
a
clean
claim
no
later
than
30
days
1
after
receiving
an
electronic
claim
submission,
or
45
days
2
after
receiving
a
claim
submitted
on
paper.
After
paying
3
a
clean
claim,
the
insurer
shall
not
retroactively
deny,
4
reduce,
or
recoup
payment
of
the
claim,
except
if
the
claim
5
submission
included
a
misrepresentation,
was
fraudulent,
or
6
was
a
duplicate
submission,
and
the
insurer
first
provides
7
written
notice
including
evidence
to
the
health
care
provider
8
(provider)
that
submitted
the
claim
of
the
misrepresentation,
9
fraud,
or
duplicate
submission.
10
If
a
health
carrier
(carrier)
conducts
an
audit
of
a
clean
11
claim,
the
carrier
shall
reimburse
the
provider
for
the
12
reasonable
administrative
costs
incurred
by
the
provider
to
13
respond
to
the
audit.
“Audit”
and
“clean
claim”
are
defined
14
in
the
bill.
15
A
carrier
that
conducts
an
audit
shall
notify
the
provider
16
of
the
initiation
of
the
audit
no
later
than
15
days
after
17
selecting
the
clean
claim
for
audit.
A
carrier
shall
complete
18
an
audit
and
issue
a
determination
on
the
clean
claim
within
19
45
days
of
receiving
all
requested
documentation
from
the
20
provider.
A
provider
that
submitted
a
clean
claim
subject
21
to
an
audit,
and
that
receives
an
adverse
determination,
may
22
appeal
the
determination
within
30
days.
A
carrier
shall
23
consider
an
appeal
and
issue
a
final
determination
on
the
clean
24
claim
no
later
than
14
days
after
receiving
notice
of
the
25
appeal.
If
a
carrier
violates
the
audit
timeline
requirements,
26
the
clean
claim
shall
be
automatically
approved
and
promptly
27
paid,
including
interest
at
the
rate
of
10
percent
per
annum.
28
The
audit
requirements
shall
not
apply
to
a
claim
that
29
is
under
active
fraud
investigation
by
a
state
or
federal
30
authority,
or
to
a
federal
program
where
audits
are
mandated
31
by
federal
law.
32
Under
the
bill,
a
carrier
shall
not:
(1)
impose
on
a
33
provider
any
financial
penalty,
reimbursement
reduction,
or
34
administrative
fee,
or
terminate
a
provider’s
participation
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in
the
carrier’s
network,
based
on
the
provider’s
referral
to
1
or
affiliation
with
an
out-of-network
provider;
(2)
interfere
2
with,
or
participate
in
any
capacity
in,
a
provider’s
decisions
3
regarding
staffing
and
referral,
except
as
otherwise
provided
4
by
law;
and
(3)
offer,
attempt
to
enforce,
or
enforce
an
5
agreement
or
amendment
to
an
agreement
with
a
provider
without
6
providing
an
opportunity
for
negotiation,
and
a
contract
term
7
that
violates
the
bill
shall
be
void
and
unenforceable.
8
A
violation
of
this
division
of
the
bill
by
a
carrier
9
shall
constitute
an
unfair
method
of
competition
or
unfair
or
10
deceptive
act
or
practice.
The
carrier
shall
be
subject
to
11
civil
penalties.
In
any
action
brought
by
a
provider
against
12
a
carrier,
the
provider
shall
be
entitled
to
recover
costs
13
of
litigation,
including
reasonable
attorney
fees
and
other
14
expenses,
regardless
of
whether
the
provider
prevails
in
such
15
action.
16
The
commissioner
shall
adopt
rules
to
administer
and
enforce
17
this
division.
18
The
bill
makes
conforming
changes
to
Code
sections
19
507B.4(3)(j)(15)
and
507B.4(3).
20
DIVISION
II
——
PRIOR
AUTHORIZATIONS.
A
utilization
review
21
organization
(URO)
shall
not
deny
or
downgrade
a
request
for
22
authorization
unless:
(1)
the
decision
is
made
by
a
qualified
23
reviewer
or
clinical
peer;
and
(2)
the
URO
provides
the
24
provider
requesting
authorization
a
written
statement
citing
25
the
reasons
for
the
decision,
explaining
the
appeals
process,
26
and
a
written
attestation
as
described
by
the
bill.
If
a
27
request
for
authorization
is
denied,
the
URO
shall
notify
28
the
provider
within
seven
days
and
conduct
a
consultation
29
as
described
by
the
bill.
“Clinical
peer”
and
“qualified
30
reviewer”
are
defined
in
the
bill.
31
If
a
URO’s
decision
to
deny
or
downgrade
a
request
for
32
authorization
is
appealed
by
the
requesting
provider
or
covered
33
person,
the
appeal
shall
be
conducted
by
a
qualified
reviewer
34
or
clinical
peer
who
was
not
involved
in
the
initial
denial
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or
downgrade.
When
conducting
an
appeal
of
a
request
for
1
authorization,
the
qualified
reviewer
or
clinical
peer
shall
2
consider
the
known
clinical
aspects
of
the
health
care
services
3
(services)
under
review,
including
but
not
limited
to
medical
4
records
relevant
to
the
medical
condition
and
any
relevant
5
medical
literature
submitted
by
the
provider.
6
A
violation
of
the
bill’s
requirements
for
denial
or
7
downgrade
of
an
authorization
by
a
URO
or
a
carrier
shall
8
constitute
an
unfair
method
of
competition
or
unfair
or
9
deceptive
act
or
practice.
The
carrier
shall
be
subject
to
10
civil
penalties.
In
any
action
brought
by
a
provider
against
11
a
carrier,
the
provider
shall
be
entitled
to
recover
costs
12
of
litigation,
including
reasonable
attorney
fees
and
other
13
expenses,
regardless
of
whether
the
provider
prevails
in
such
14
action.
15
The
commissioner
may
adopt
rules
to
administer
this
division
16
of
the
bill.
17
A
carrier
shall
not
require
authorization
for,
or
impose
18
additional
utilization
review
requirements
on,
a
covered
19
person
for:
(1)
a
cancer-related
screening
or
cancer-related
20
preventative
service
recommended
by
the
covered
person’s
21
professional
based
on
the
national
comprehensive
cancer
network
22
clinical
practice
guidelines
in
oncology;
or
(2)
the
diagnosis
23
and
treatment
of
a
health
condition
that
develops
or
becomes
24
evident
in
a
covered
person
while
receiving
treatment
at
an
25
inpatient
facility,
and
the
health
condition
is
reasonably
26
determined
by
a
professional
to
be
a
life
threatening
condition
27
unless
the
covered
person
receives
immediate
assessment
and
28
treatment.
29
This
division
of
the
bill
applies
to
health
benefit
plans
30
delivered,
issued
for
delivery,
continued,
or
renewed
on
or
31
after
January
1,
2027,
and
requests
for
prior
authorization
32
for
a
cancer-related
screening
or
cancer-related
preventative
33
health
care
service
if
the
screening
or
service
is
recommended
34
by
the
covered
person’s
professional,
the
request
is
made
35
-15-
LSB
5772YH
(7)
91
nls/ko
15/
16
H.F.
2438
before
January
1,
2027,
and
the
request
has
not
been
finally
1
determined
on
or
before
that
date.
2
-16-
LSB
5772YH
(7)
91
nls/ko
16/
16