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FILE
2421
BY
COMMITTEE
ON
HEALTH
AND
HUMAN
SERVICES
(SUCCESSOR
TO
SSB
3118)
A
BILL
FOR
An
Act
relating
to
utilization
review
organizations’
use
of
1
artificial
intelligence,
prior
authorization
determinations
2
and
exemptions,
and
audits,
and
including
applicability
3
provisions.
4
BE
IT
ENACTED
BY
THE
GENERAL
ASSEMBLY
OF
THE
STATE
OF
IOWA:
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DIVISION
I
1
PRIOR
AUTHORIZATION
——
USE
OF
ARTIFICIAL
INTELLIGENCE
AND
PEER
2
REVIEW
3
Section
1.
Section
514F.8,
subsection
1,
Code
2026,
is
4
amended
by
adding
the
following
new
paragraph:
5
NEW
PARAGRAPH
.
0b.
“Downgrade”
means
a
decision
by
a
6
health
carrier
or
utilization
review
organization
to
change
7
an
expedited
or
urgent
request
for
prior
authorization
8
to
a
standard
determination,
or
otherwise
modify
a
health
9
care
service
that
is
the
subject
of
a
request
for
prior
10
authorization
to
a
lower-level
health
care
service.
11
Sec.
2.
Section
514F.8,
Code
2026,
is
amended
by
adding
the
12
following
new
subsection:
13
NEW
SUBSECTION
.
2A.
A
utilization
review
organization
may
14
use
an
artificial
intelligence-based
algorithm
to
provide
an
15
initial
review
of
a
request
for
prior
authorization,
except
16
that,
for
a
prior
authorization
request
for
a
health
care
17
service
based
on
medical
necessity,
a
utilization
review
18
organization
shall
not
use
an
artificial
intelligence-based
19
algorithm
as
the
sole
basis
for
the
utilization
review
20
organization’s
decision
to
deny,
delay,
or
downgrade
the
prior
21
authorization
request.
22
Sec.
3.
NEW
SECTION
.
514F.8A
Prior
authorizations
——
peer
23
review.
24
1.
For
purposes
of
this
section:
25
a.
“Clinical
peer”
means
a
health
care
professional
that
26
meets
all
of
the
following
requirements:
27
(1)
The
health
care
professional
practices
in
the
same
or
28
similar
specialty
as
the
health
care
provider
that
requested
29
a
prior
authorization.
30
(2)
The
health
care
professional
has
experience
managing
31
the
specific
medical
condition
or
administering
the
health
care
32
service
that
is
the
subject
of
the
prior
authorization
request.
33
(3)
The
health
care
professional
is
employed
by
or
34
contracted
with
the
utilization
review
organization
or
health
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carrier
to
which
a
health
care
provider
submitted
a
request
for
1
prior
authorization.
2
b.
“Covered
person”
means
the
same
as
defined
in
section
3
514F.8.
4
c.
“Downgrade”
means
a
decision
by
a
health
carrier
5
or
utilization
review
organization
to
change
an
expedited
6
or
urgent
request
for
prior
authorization
to
a
standard
7
determination,
or
otherwise
modify
a
health
care
service
that
8
is
the
subject
of
a
request
for
prior
authorization
to
a
9
lower-level
health
care
service.
10
d.
“Health
care
professional”
means
the
same
as
defined
in
11
section
514J.102.
12
e.
“Health
care
provider”
means
the
same
as
defined
in
13
section
514F.8.
14
f.
“Health
care
services”
means
the
same
as
defined
in
15
section
514F.8.
16
g.
“Health
carrier”
means
the
same
as
defined
in
section
17
514F.8.
18
h.
“Physician”
means
a
licensed
doctor
of
medicine
and
19
surgery
or
a
licensed
doctor
of
osteopathic
medicine
and
20
surgery
licensed
under
chapter
148.
21
i.
“Prior
authorization”
means
the
same
as
defined
in
22
section
514F.8.
23
j.
“Qualified
reviewer”
means
a
physician
that
meets
all
of
24
the
following
requirements:
25
(1)
The
physician
practices
in
the
same
or
a
similar
26
specialty
as
the
health
care
provider
that
requested
a
prior
27
authorization.
28
(2)
The
physician
has
the
training
and
expertise
to
treat
29
the
specific
medical
condition
that
is
the
subject
of
a
30
request
for
prior
authorization,
including
sufficient
knowledge
31
to
determine
whether
the
health
care
service
that
is
the
32
subject
of
the
request
is
medically
necessary
or
clinically
33
appropriate.
34
(3)
The
physician
is
employed
by
or
contracted
with
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the
utilization
review
organization
or
health
carrier
to
1
which
a
health
care
provider
submitted
a
request
for
prior
2
authorization.
3
k.
“Utilization
review
organization”
means
the
same
as
4
defined
in
section
514F.8.
5
2.
A
utilization
review
organization
shall
not
deny
or
6
downgrade
a
request
for
prior
authorization
unless
all
of
the
7
following
requirements
are
met:
8
a.
The
decision
to
deny
or
downgrade
the
request
is
made
by
9
either
of
the
following:
10
(1)
A
qualified
reviewer,
if
the
health
care
provider
11
requesting
prior
authorization
is
a
physician.
12
(2)
A
clinical
peer,
if
the
health
care
provider
requesting
13
prior
authorization
is
not
a
physician.
14
b.
The
utilization
review
organization
provides
the
health
15
care
provider
that
requested
the
prior
authorization
all
of
the
16
following:
17
(1)
A
written
statement
that
cites
the
specific
reasons
18
for
the
denial
or
downgrade,
including
any
coverage
criteria
19
or
limits,
or
clinical
criteria,
that
the
utilization
review
20
organization
considered
or
that
was
the
basis
for
the
denial
21
or
downgrade.
The
written
statement
shall
be
signed
by
either
22
of
the
following:
23
(a)
The
qualified
reviewer
that
made
the
denial
or
downgrade
24
determination,
if
the
health
care
provider
that
requested
prior
25
authorization
is
a
physician.
26
(b)
The
clinical
peer
that
made
the
denial
or
downgrade
27
determination,
if
the
health
care
provider
that
requested
prior
28
authorization
is
not
a
physician.
29
(2)
A
written
explanation
of
the
utilization
review
30
organization’s
appeals
process.
The
utilization
review
31
organization
shall
also
provide
the
written
explanation
to
the
32
covered
person
for
whom
prior
authorization
was
requested.
33
(3)
A
written
attestation
that
is
either
of
the
following:
34
(a)
If
the
health
care
provider
that
requested
prior
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authorization
is
a
physician,
a
written
attestation
that
1
the
qualified
reviewer
who
made
the
denial
or
downgrade
2
determination
practices
in
the
same
or
a
similar
specialty
as
3
the
health
care
provider,
and
has
the
requisite
training
and
4
expertise
to
treat
the
medical
condition
that
is
the
subject
5
of
the
request
for
prior
authorization,
including
sufficient
6
knowledge
to
determine
whether
the
health
care
service
is
7
medically
necessary
or
clinically
appropriate.
The
attestation
8
shall
include
the
qualified
reviewer’s
name,
national
provider
9
identifier,
board
certifications,
specialty
expertise,
and
10
educational
background.
11
(b)
If
the
health
care
provider
that
requested
prior
12
authorization
is
not
a
physician,
a
written
attestation
13
that
the
clinical
peer
who
made
the
denial
or
downgrade
14
determination
practices
in
the
same
or
a
similar
specialty
as
15
the
health
care
provider,
and
the
clinical
peer
has
experience
16
managing
the
specific
medical
condition
or
administering
17
the
health
care
service
that
is
the
subject
of
the
request
18
for
prior
authorization.
The
attestation
shall
include
19
the
clinical
peer’s
name,
national
provider
identifier,
20
board
certifications,
specialty
expertise,
and
educational
21
background.
22
3.
A
utilization
review
organization
that
denies
a
request
23
for
prior
authorization
shall,
no
later
than
seven
business
24
days
after
the
date
that
the
utilization
review
organization
25
notifies
the
requesting
health
care
provider
of
the
denial,
26
conduct
a
consultation
either
in
person
or
remotely,
as
27
follows:
28
a.
Between
the
health
care
provider
and
a
qualified
29
reviewer,
if
the
health
care
provider
requesting
prior
30
authorization
is
a
physician.
31
b.
Between
the
health
care
provider
and
a
clinical
peer,
if
32
the
health
care
provider
requesting
prior
authorization
is
not
33
a
physician.
34
4.
a.
If
a
utilization
review
organization’s
decision
to
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deny
or
downgrade
a
request
for
prior
authorization
is
appealed
1
by
the
requesting
health
care
provider
or
covered
person,
the
2
appeal
shall
be
conducted
by
either
of
the
following:
3
(1)
A
qualified
reviewer,
if
the
health
care
provider
4
requesting
prior
authorization
is
a
physician.
5
(2)
A
clinical
peer,
if
the
health
care
provider
requesting
6
prior
authorization
is
not
a
physician.
7
b.
A
qualified
reviewer
or
clinical
peer
involved
in
the
8
initial
denial
or
downgrade
determination
of
a
request
for
9
prior
authorization
that
is
the
subject
of
an
appeal
shall
not
10
conduct
the
appeal.
11
c.
When
conducting
an
appeal
of
a
request
for
prior
12
authorization,
the
qualified
reviewer
or
clinical
peer
shall
13
consider
the
known
clinical
aspects
of
the
health
care
services
14
under
review,
including
but
not
limited
to
medical
records
15
relevant
to
the
covered
person’s
medical
condition
that
16
is
the
subject
of
the
health
care
services
for
which
prior
17
authorization
is
requested,
and
any
relevant
medical
literature
18
submitted
by
the
health
care
provider
as
part
of
the
appeal.
19
5.
The
commissioner
of
insurance
may
adopt
rules
pursuant
to
20
chapter
17A
to
administer
this
section.
21
Sec.
4.
APPLICABILITY.
This
division
of
this
Act
applies
22
to
all
of
the
following:
23
1.
Requests
for
prior
authorization
made
before
January
24
1,
2027,
if
the
request
has
not
been
finally
determined
on
or
25
before
that
date.
26
2.
Requests
for
prior
authorization
made
on
or
after
January
27
1,
2027.
28
DIVISION
II
29
PRIOR
AUTHORIZATION
——
CANCER-RELATED
EXEMPTIONS
30
Sec.
5.
NEW
SECTION
.
514F.8B
Prior
authorizations
——
31
exemptions
for
cancer-related
screenings.
32
1.
For
purposes
of
this
section:
33
a.
“Covered
person”
means
the
same
as
defined
in
section
34
514F.8.
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b.
“Health
benefit
plan”
means
the
same
as
defined
in
1
section
514J.102.
2
c.
“Health
care
professional”
means
the
same
as
defined
in
3
section
514J.102.
4
d.
“Health
carrier”
means
an
entity
subject
to
the
5
insurance
laws
and
regulations
of
this
state,
or
subject
6
to
the
jurisdiction
of
the
commissioner,
including
an
7
insurance
company
offering
sickness
and
accident
plans,
a
8
health
maintenance
organization,
a
nonprofit
health
service
9
corporation,
a
plan
established
pursuant
to
chapter
509A
10
for
public
employees,
or
any
other
entity
providing
a
plan
11
of
health
insurance,
health
care
benefits,
or
health
care
12
services.
“Health
carrier”
includes
the
following:
13
(1)
The
medical
assistance
program
under
chapter
249A
and
14
the
healthy
and
well
kids
in
Iowa
(Hawki)
program
under
chapter
15
514I.
16
(2)
A
managed
care
organization
acting
pursuant
to
a
17
contract
with
the
department
of
health
and
human
services
to
18
administer
the
medical
assistance
program
under
chapter
249A,
19
or
the
healthy
and
well
kids
in
Iowa
(Hawki)
program
under
20
chapter
514I.
21
e.
“Prior
authorization”
means
the
same
as
defined
in
22
section
514F.8.
23
f.
“Utilization
review”
means
the
same
as
defined
in
section
24
514F.4,
subsection
3.
25
2.
A
health
carrier
shall
not
require
prior
authorization
26
for,
or
impose
additional
utilization
review
requirements
on,
a
27
covered
person
for
a
cancer-related
screening
if
the
screening
28
is
recommended
by
the
covered
person’s
health
care
professional
29
based
on
the
most
recently
updated
national
comprehensive
30
cancer
network
clinical
practice
guidelines
in
oncology.
31
3.
The
director
of
health
and
human
services
shall
adopt
32
rules
pursuant
to
chapter
17A
to
administer
this
section,
33
including
but
not
limited
to
rules
relating
to
all
of
the
34
following:
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a.
The
medical
assistance
program
under
chapter
249A
and
1
the
healthy
and
well
kids
in
Iowa
(Hawki)
program
under
chapter
2
514I.
3
b.
A
managed
care
organization
acting
pursuant
to
a
contract
4
with
the
department
of
health
and
human
services
to
administer
5
the
medical
assistance
program
under
chapter
249A,
or
the
6
healthy
and
well
kids
in
Iowa
(Hawki)
program
under
chapter
7
514I.
8
4.
The
commissioner
of
insurance
may
adopt
rules
pursuant
9
to
chapter
17A
to
administer
this
section,
except
as
otherwise
10
provided
in
subsection
3.
11
Sec.
6.
APPLICABILITY.
This
division
of
this
Act
applies
12
to
all
of
the
following:
13
1.
Health
benefit
plans
delivered,
issued
for
delivery,
14
continued,
or
renewed
in
this
state
on
or
after
January
1,
15
2027.
16
2.
Requests
for
prior
authorization
for
a
cancer-related
17
screening
if
the
screening
is
recommended
by
the
covered
18
person’s
health
care
professional
based
on
the
most
recently
19
updated
national
comprehensive
cancer
network
clinical
practice
20
guidelines
in
oncology,
the
request
is
made
before
January
1,
21
2027,
and
the
request
has
not
been
finally
determined
on
or
22
before
that
date.
23
3.
Requests
for
prior
authorization
for
a
cancer-related
24
screening,
if
the
screening
is
recommended
by
the
covered
25
person’s
health
care
professional
based
on
the
most
recently
26
updated
national
comprehensive
cancer
network
clinical
practice
27
guidelines
in
oncology,
made
on
or
after
January
1,
2027.
28
DIVISION
III
29
PRIOR
AUTHORIZATION
——
LIFE-THREATENING
HEALTH
CONDITIONS
30
Sec.
7.
NEW
SECTION
.
514F.8C
Prior
authorizations
——
31
exemptions
for
life-threatening
health
conditions.
32
1.
For
purposes
of
this
section:
33
a.
“Covered
person”
means
the
same
as
defined
in
section
34
514F.8.
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b.
“Health
benefit
plan”
means
the
same
as
defined
in
1
section
514J.102.
2
c.
“Health
care
professional”
means
the
same
as
defined
in
3
section
514J.102.
4
d.
“Health
carrier”
means
the
same
as
defined
in
section
5
514F.8.
6
e.
“Prior
authorization”
means
the
same
as
defined
in
7
section
514F.8.
8
f.
“Utilization
review”
means
the
same
as
defined
in
section
9
514F.4,
subsection
3.
10
2.
A
health
carrier
shall
not
require
prior
authorization
11
for,
or
impose
additional
utilization
review
requirements
12
on,
a
covered
person
for
diagnosis
and
treatment
of
a
health
13
condition
that
develops
or
becomes
evident
in
a
covered
person
14
while
the
covered
person
is
receiving
treatment
at
an
inpatient
15
facility,
and
the
health
condition
is
reasonably
determined
by
16
a
health
care
professional
to
be
a
life-threatening
condition
17
unless
the
covered
person
receives
immediate
assessment
and
18
treatment.
19
3.
The
commissioner
of
insurance
may
adopt
rules
pursuant
to
20
chapter
17A
to
administer
this
section.
21
Sec.
8.
APPLICABILITY.
This
division
of
this
Act
applies
22
to
all
of
the
following:
23
1.
Health
benefit
plans
delivered,
issued
for
delivery,
24
continued,
or
renewed
in
this
state
on
or
after
January
1,
25
2027.
26
2.
Requests
for
prior
authorization
for
diagnosis
and
27
treatment
of
a
health
condition
that
develops
or
becomes
28
evident
in
a
covered
person
while
the
covered
person
29
is
receiving
treatment
at
an
inpatient
facility
if
the
30
health
condition
is
reasonably
determined
by
a
health
care
31
professional
to
be
a
life-threatening
condition
unless
the
32
covered
person
receives
immediate
assessment
and
treatment,
the
33
request
is
made
before
January
1,
2027,
and
the
request
has
not
34
been
finally
determined
on
or
before
that
date.
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DIVISION
IV
1
UTILIZATION
REVIEW
ORGANIZATIONS
——
PREPAYMENT
AUDITS
2
Sec.
9.
NEW
SECTION
.
514F.10
Utilization
review
3
organizations
——
prepayment
audits.
4
1.
For
purposes
of
this
section:
5
a.
“Audit”
means
a
review,
investigation,
or
request
for
6
additional
documentation
by
a
health
carrier
or
utilization
7
review
organization
on
behalf
of
the
health
carrier
prior
to
or
8
after
issuing
payment
on
a
claim
to
a
health
care
provider.
9
b.
“Health
care
provider”
means
the
same
as
defined
in
10
section
514F.8.
11
c.
“Health
carrier”
means
the
same
as
defined
in
section
12
514F.8.
13
d.
“Utilization
review
organization”
means
the
same
as
14
defined
in
section
514F.8.
15
2.
A
health
carrier
or
utilization
review
organization
that
16
conducts
an
audit
shall
notify
the
health
care
provider
that
17
submitted
the
claim
of
the
initiation
of
the
audit
no
later
18
than
fifteen
calendar
days
after
the
date
the
health
carrier
19
selects
the
claim
for
audit.
20
3.
A
health
carrier
or
utilization
review
organization
21
shall
complete
an
audit
of
a
claim
and
issue
a
determination
22
on
the
claim
to
the
health
care
provider
that
submitted
23
the
claim
no
later
than
forty-five
calendar
days
after
the
24
date
that
the
utilization
review
organization
receives
all
25
requested
documentation
regarding
the
claim
from
the
health
26
care
provider.
27
4.
A
health
care
provider
that
submitted
a
claim
that
is
28
the
subject
of
an
audit
by
a
health
carrier
or
utilization
29
review
organization,
and
that
receives
an
adverse
determination
30
regarding
the
claim,
may
appeal
the
adverse
determination
no
31
later
than
thirty
calendar
days
after
the
date
the
health
care
32
provider
receives
the
audit
determination.
33
5.
A
health
carrier
or
utilization
review
organization
34
shall
consider
an
appeal
under
subsection
4,
and
issue
a
final
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determination
on
the
claim
that
is
the
subject
of
the
appeal,
1
no
later
than
fourteen
calendar
days
after
that
date
the
health
2
carrier
or
utilization
review
organization
receives
notice
of
3
the
appeal.
4
6.
If
a
health
carrier
or
utilization
review
organization
5
violates
this
section,
the
claim
shall
be
automatically
6
approved
by
the
health
carrier
or
utilization
review
7
organization
and
promptly
paid
pursuant
to
section
507B.4A,
8
subsection
2.
9
7.
The
commissioner
of
insurance
may
adopt
rules
pursuant
to
10
chapter
17A
to
administer
and
enforce
this
section.
11
Sec.
10.
APPLICABILITY.
This
division
of
this
Act
applies
12
to
audits
initiated
on
or
after
January
1,
2027.
13
EXPLANATION
14
The
inclusion
of
this
explanation
does
not
constitute
agreement
with
15
the
explanation’s
substance
by
the
members
of
the
general
assembly.
16
This
bill
relates
to
utilization
review
organizations’
use
17
of
artificial
intelligence,
prior
authorization
determinations
18
and
exemptions,
and
audits.
19
DIVISION
I
——
PRIOR
AUTHORIZATION
——
USE
OF
ARTIFICIAL
20
INTELLIGENCE
AND
PEER
REVIEW.
Under
the
bill,
a
21
utilization
review
organization
(URO)
may
use
an
artificial
22
intelligence-based
algorithm
to
provide
an
initial
review
of
23
a
request
for
prior
authorization
(authorization),
except
24
that,
for
a
request
for
a
health
care
service
(service)
25
based
on
medical
necessity,
a
URO
shall
not
use
an
artificial
26
intelligence-based
algorithm
as
the
sole
basis
for
a
decision
27
to
deny,
delay,
or
downgrade
the
authorization
request.
28
“Downgrade”
is
defined
in
the
bill.
29
A
URO
shall
not
deny
or
downgrade
a
request
for
authorization
30
unless
the
decision
is
made
by
a
qualified
reviewer
or
clinical
31
peer
and
the
URO
provides
the
health
care
provider
(provider)
32
requesting
authorization
a
written
statement
citing
the
33
reasons
for
the
decision,
explaining
the
appeals
process,
and
34
a
written
attestation
as
described
by
the
bill.
If
a
request
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for
authorization
is
denied,
the
URO
shall
notify
the
provider
1
within
seven
days
and
conduct
a
consultation
as
described
by
2
the
bill.
“Clinical
peer”
and
“qualified
reviewer”
are
defined
3
in
the
bill.
4
If
a
URO’s
decision
to
deny
or
downgrade
a
request
for
5
authorization
is
appealed
by
the
requesting
provider
or
covered
6
person
(person),
the
appeal
shall
be
conducted
by
a
qualified
7
reviewer
or
clinical
peer
who
was
not
involved
in
the
initial
8
denial
or
downgrade.
When
conducting
an
appeal,
the
qualified
9
reviewer
or
clinical
peer
shall
consider
the
known
clinical
10
aspects
of
the
services
under
review.
11
The
commissioner
of
insurance
(commissioner)
may
adopt
rules
12
to
administer
this
division
of
the
bill.
13
This
division
of
the
bill
applies
to
requests
for
14
authorization
made
before
January
1,
2027,
if
the
request
15
has
not
been
finally
determined
on
or
before
that
date,
and
16
requests
for
authorization
made
on
or
after
January
1,
2027.
17
DIVISION
II
——
PRIOR
AUTHORIZATION
——
CANCER-RELATED
18
EXEMPTIONS.
A
health
carrier
(carrier)
shall
not
require
19
authorization
for,
or
impose
additional
utilization
review
20
requirements
on,
a
person
for
a
cancer-related
screening
21
(screening)
if
the
screening
is
recommended
by
the
person’s
22
health
care
professional
(professional)
based
on
the
most
23
recently
updated
national
comprehensive
cancer
network
clinical
24
practice
guidelines
in
oncology.
The
director
of
health
25
and
human
services
shall
adopt
rules,
and
the
commissioner
26
may
adopt
rules,
to
administer
this
division
of
the
bill
as
27
detailed
in
the
bill.
28
This
division
of
the
bill
applies
to
health
benefit
plans
29
(plans)
delivered,
issued
for
delivery,
continued,
or
renewed
30
on
or
after
January
1,
2027,
and
requests
for
authorization
31
for
a
screening
recommended
by
a
person’s
professional
if
32
the
request
is
made
before
January
1,
2027,
and
has
not
been
33
finally
determined
on
or
before
that
date.
The
bill
also
34
applies
to
such
requests
made
on
or
after
January
1,
2027.
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DIVISION
III
——
PRIOR
AUTHORIZATION
——
LIFE-THREATENING
1
HEALTH
CONDITIONS.
A
carrier
shall
not
require
authorization
2
for,
or
impose
additional
utilization
review
requirements
on,
3
a
person
for
diagnosis
and
treatment
of
a
health
condition
4
(condition)
that
develops
or
becomes
evident
while
the
5
person
is
receiving
treatment
at
an
inpatient
facility
6
and
is
reasonably
determined
by
a
professional
to
be
a
7
life-threatening
condition
unless
the
person
receives
immediate
8
assessment
and
treatment.
The
commissioner
may
adopt
rules
to
9
administer
this
division
of
the
bill.
10
This
division
of
the
bill
applies
to
plans
delivered,
11
issued
for
delivery,
continued,
or
renewed
on
or
after
January
12
1,
2027,
and
requests
for
authorization
for
diagnosis
and
13
treatment
of
a
condition
that
develops
or
becomes
evident
in
a
14
person
while
receiving
treatment
at
an
inpatient
facility
if
15
the
condition
is
life-threatening
unless
the
person
receives
16
immediate
assessment
and
treatment,
the
request
is
made
17
before
January
1,
2027,
and
the
request
has
not
been
finally
18
determined
on
or
before
that
date.
19
DIVISION
IV
——
UTILIZATION
REVIEW
ORGANIZATIONS
——
AUDITS.
20
A
carrier
or
URO
that
conducts
an
audit
shall
notify
the
21
provider
that
submitted
the
claim
of
the
initiation
of
the
22
audit
no
later
than
15
days
after
the
carrier
selects
the
23
claim
for
audit.
“Audit”
is
defined
in
the
bill.
A
carrier
24
or
URO
shall
complete
an
audit
and
issue
a
determination
25
to
the
provider
no
later
than
45
days
after
the
carrier
or
26
URO
receives
all
documentation
regarding
the
claim
from
the
27
provider.
28
A
provider
who
submitted
a
claim
that
is
the
subject
of
an
29
audit
and
who
receives
an
adverse
determination
regarding
the
30
claim
may
appeal
it
no
later
than
30
days
after
the
provider
31
receives
the
determination.
A
carrier
or
URO
shall
consider
32
an
appeal
and
issue
a
final
determination
no
later
than
14
33
days
after
receiving
notice
of
an
appeal.
If
a
carrier
or
URO
34
violates
the
bill,
the
claim
shall
be
automatically
approved
by
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the
carrier
or
URO
and
promptly
paid,
including
interest.
1
The
commissioner
may
adopt
rules
to
administer
and
enforce
2
this
division
of
the
bill.
3
This
division
of
the
bill
applies
to
audits
initiated
on
or
4
after
January
1,
2027.
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