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Senate
File
231
-
Introduced
SENATE
FILE
231
BY
COMMITTEE
ON
HEALTH
AND
HUMAN
SERVICES
(SUCCESSOR
TO
SSB
1016)
A
BILL
FOR
An
Act
relating
to
prior
authorization
and
utilization
review
1
organizations.
2
BE
IT
ENACTED
BY
THE
GENERAL
ASSEMBLY
OF
THE
STATE
OF
IOWA:
3
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Section
1.
Section
514F.8,
Code
2025,
is
amended
by
adding
1
the
following
new
subsections:
2
NEW
SUBSECTION
.
1A.
a.
A
utilization
review
organization
3
shall
provide
a
determination
to
a
request
for
prior
4
authorization
from
a
health
care
provider
as
follows:
5
(1)
Within
forty-eight
hours
after
receipt
for
urgent
6
requests.
7
(2)
Within
ten
calendar
days
after
receipt
for
nonurgent
8
requests.
9
(3)
Within
fifteen
calendar
days
after
receipt
for
10
nonurgent
requests
if
there
are
complex
or
unique
circumstances
11
or
the
utilization
review
organization
is
experiencing
an
12
unusually
high
volume
of
prior
authorization
requests.
13
b.
Within
twenty-four
hours
after
receipt
of
a
prior
14
authorization
request,
the
utilization
review
organization
15
shall
notify
the
health
care
provider
of,
or
make
available
to
16
the
health
care
provider,
a
receipt
for
the
request
for
prior
17
authorization.
18
c.
A
utilization
review
organization
shall
conduct
an
annual
19
review
and
submit
the
findings
in
a
report
to
the
commissioner
20
pursuant
to
the
reporting
procedures
and
deadlines
established
21
by
the
commissioner.
The
annual
report
shall
include
all
of
22
the
following:
23
(1)
The
total
number
of,
and
percentage
of,
urgent
prior
24
authorization
requests
that
the
utilization
review
organization
25
approved,
aggregated
for
all
health
care
services
and
items.
26
(2)
The
total
number
of,
and
percentage
of,
urgent
prior
27
authorization
requests
that
the
utilization
review
organization
28
denied,
aggregated
for
all
health
care
services
or
items.
29
(3)
The
total
number
of,
and
percentage
of,
nonurgent
prior
30
authorization
requests
that
the
utilization
review
organization
31
approved,
aggregated
for
all
health
care
services
or
items.
32
(4)
The
total
number
of,
and
percentage
of,
nonurgent
prior
33
authorization
requests
that
the
utilization
review
organization
34
denied,
aggregated
for
all
health
care
services
or
items.
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(5)
The
total
number
of,
and
percentage
of,
nonurgent
1
prior
authorization
requests
that
were
complex
or
involved
2
unique
circumstances
that
the
utilization
review
organization
3
approved,
aggregated
for
all
health
care
services
or
items.
4
(6)
The
average
and
median
time
that
elapsed
between
the
5
submission
of
a
prior
authorization
request
and
a
determination
6
by
the
utilization
review
organization
for
the
prior
7
authorization
request,
aggregated
for
all
health
care
services
8
or
items.
9
(7)
The
average
and
median
time
that
elapsed
between
the
10
submission
of
an
urgent
prior
authorization
request
and
a
11
determination
by
the
utilization
review
organization
for
the
12
urgent
prior
authorization
request,
aggregated
for
all
health
13
care
services
or
items.
14
(8)
The
average
and
median
time
that
elapsed
between
the
15
submission
of
a
nonurgent
prior
authorization
request
and
a
16
determination
by
the
utilization
review
organization
for
the
17
urgent
prior
authorization
request,
aggregated
for
all
health
18
care
services
or
items.
19
NEW
SUBSECTION
.
2A.
a.
A
utilization
review
organization
20
shall,
at
least
annually,
review
all
health
care
services
for
21
which
the
health
benefit
plan
requires
prior
authorization
and
22
shall
eliminate
prior
authorization
requirements
for
health
23
care
services
for
which
prior
authorization
requests
are
24
routinely
approved
with
such
frequency
as
to
demonstrate
that
25
the
prior
authorization
requirement
does
not
promote
health
26
care
quality,
or
reduce
health
care
spending,
to
a
degree
27
sufficient
to
justify
the
health
benefit
plan’s
administrative
28
costs
to
require
the
prior
authorization.
29
b.
(1)
A
utilization
review
organization
shall
submit
30
an
annual
report
containing
the
findings
of
the
review
31
conducted
under
paragraph
“a”
to
the
commissioner
pursuant
32
to
the
reporting
procedures
and
deadlines
established
by
the
33
commissioner.
The
annual
report
shall
include
all
of
the
34
following:
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(a)
The
total
number
of
prior
authorizations
the
1
utilization
review
organization
evaluated
as
part
of
the
annual
2
review.
3
(b)
The
number
of
prior
authorizations
the
utilization
4
review
organization
eliminated
as
a
result
of
the
annual
5
review,
and
the
reason
for
the
elimination.
6
(c)
A
list
of
prior
authorizations
that
had
at
least
eighty
7
percent
of
requests
approved
in
the
previous
twelve
months
for
8
a
specific
health
care
service
covered
by
a
health
benefit
9
plan,
but
which
prior
authorizations
were
retained
due
to
10
medical
or
scientific
evidence,
as
defined
in
section
514J.102,
11
that
justified
continuing
such
requirement.
12
(d)
The
total
number
of
prior
authorization
requests
13
submitted
in
the
previous
twelve
months
for
each
eliminated
14
prior
authorization,
and
the
total
number
of
health
care
15
providers
that
submitted
a
request
for
prior
authorization
16
in
the
previous
twelve
months
for
each
eliminated
prior
17
authorization
requirement.
18
(e)
For
each
health
care
service
for
which
prior
19
authorization
was
eliminated
under
subparagraph
division
20
(b),
the
report
shall
include
data
regarding
any
increase
or
21
decrease
of
ten
percent
or
greater
in
the
average
number
of
22
claims
submitted
per
health
care
provider
for
that
health
care
23
service
compared
to
the
twelve
months
immediately
preceding
the
24
elimination
of
the
prior
authorization.
25
(2)
The
commissioner
shall
submit
an
annual
report
to
the
26
general
assembly
that
includes
a
summary
and
analysis
of
the
27
information
reported
under
this
paragraph
and
the
information
28
reported
under
subsection
1A,
paragraph
“c”
.
29
NEW
SUBSECTION
.
3A.
Complaints
regarding
a
utilization
30
review
organization’s
compliance
with
this
chapter
may
be
31
directed
to
the
insurance
division.
The
insurance
division
32
shall
notify
a
utilization
review
organization
of
all
33
complaints
regarding
the
utilization
review
organization’s
34
noncompliance
with
this
chapter.
All
complaints
received
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pursuant
to
this
subsection
shall
not
be
considered
public
1
records
for
purposes
of
chapter
22.
2
EXPLANATION
3
The
inclusion
of
this
explanation
does
not
constitute
agreement
with
4
the
explanation’s
substance
by
the
members
of
the
general
assembly.
5
This
bill
relates
to
prior
authorization
and
utilization
6
review
organizations.
7
The
bill
requires
a
utilization
review
organization
8
(organization)
to
provide
a
determination
to
a
request
for
9
prior
authorization
(authorization)
from
a
health
care
provider
10
(provider)
within
48
hours
after
receipt
for
urgent
requests
11
or
within
10
calendar
days
for
nonurgent
requests,
unless
12
there
are
complex
or
unique
circumstances,
or
the
organization
13
is
experiencing
an
unusually
high
volume
of
authorization
14
requests,
then
an
organization
must
respond
within
15
calendar
15
days.
Within
24
hours
after
receipt
of
an
authorization
16
request,
the
organization
shall
notify
a
provider
of,
or
make
17
available,
a
receipt
for
the
authorization
request.
18
The
bill
requires
an
organization
to
conduct
an
annual
19
review
and
submit
the
findings
in
a
report
to
the
commissioner
20
of
insurance
(commissioner).
The
requirements
for
the
21
report
are
detailed
in
the
bill.
The
bill
also
requires
an
22
organization
to
annually
review
all
health
care
services
for
23
which
a
health
benefit
plan
(plan)
requires
an
authorization,
24
and
to
eliminate
authorization
requirements
for
health
care
25
services
for
which
authorization
requests
are
so
routinely
26
approved
that
the
authorization
requirement
is
not
justified
27
as
it
does
not
promote
health
care
quality
or
reduce
health
28
care
spending.
An
organization
shall
submit
an
annual
report
29
containing
the
findings
of
both
reviews
to
the
commissioner,
30
and
shall
include
all
of
the
information
detailed
in
the
bill.
31
The
commissioner
shall
submit
an
annual
report
to
the
general
32
assembly
containing
a
summary
and
analysis
of
the
information
33
in
the
reports.
34
Complaints
regarding
an
organization’s
compliance
with
35
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231
the
bill
may
be
directed
to
the
insurance
division,
and
1
the
insurance
division
shall
notify
an
organization
of
all
2
complaints
received
regarding
the
organization.
Complaints
3
received
under
the
bill
shall
not
be
considered
public
records.
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