Creates provisions relating to prior authorization of health care services

SECOND REGULAR SESSION
HOUSE BILL NO. 1675
103RD GENERAL ASSEMBL Y
INTRODUCED BY REPRESENT A TIVE SEITZ.
3871H.01I JOSEPH ENGLER, Chief Clerk
AN ACT
T o amend chapter 376, RSMo, by adding thereto five new sections relating to prior
authorization of health care services.
Be it enacted by the General Assembly of the state of Missouri, as follows:
Section A. Chapter 376, RSMo, is amended by adding thereto five new sections, to be
2 known as sections 376.2100, 376.2102, 376.2104, 376.2106, and 376.2108, to read as
3 follows:
376.2100. 1. Except as otherwise pr ovided in subsection 1 of section 376.2108, as
2 used in sections 376.2100 to 376.2108, terms shall have the same meanings as are
3 ascribed to them under section 376.1350.
4 2. As used in sections 376.2100 to 376.2108, the term "evaluation period" shall
5 mean the first six months of the calendar year or the last six months of the calendar
6 year .
376.2102. 1. A health carrier or utilization review entity shall not req uire a
2 health car e pr ovider to obtain prior authorization for a health care service unless the
3 health carrier or utilization r eview entity makes a determination that in the most recent
4 evaluation period the health carrier or utilization revi ew entity has appr oved or would
5 have appr oved less than ninety percen t of the prior authorization r equests submitted by
6 that pr ovider for that health car e service.
7 2. A health carrier or utilization r eview entity shall not r equir e a health car e
8 pr ovider to obtain prior authorization for any health care services unless the health
9 carrier or utilization review entity makes a determination that in the most recen t
10 evaluation period the health carrier or utilization revi ew entity has appr oved or would
EXPLANA TION — Matter enclosed in bold-faced brackets [thus] in the above bill is not enacted and is
intended to be omitted from the law . Matter in bold-face type in the above bill is proposed language.
11 have appr oved less than ninety per cent of all prior authorization req uests submitted by
12 that pr ovider for health car e services.
13 3. In making a determination under this section, the health carrier or utilization
14 r eview entity shall not count any prior authorization req uests denied by a health carrier
15 or utilization revi ew entity and being appealed by the health care pr ovider but shall
16 count as appr oved any prior authorization r equest that was denied by a health carrier
17 or utilization r eview entity but that was subsequently authorized.
376.2104. 1. The health carrier or utilization review entity shall notify the health
2 car e prov ider no later than twenty-five days after the conclusion of the r elevant
3 evaluation period of any determination made under section 376.2102. The notification
4 shall include the statistics, data, and any supporting documentation for making the
5 determination for the relev ant evaluation period.
6 2. The health carrier or utilization rev iew entity shall establish a pr ocess for
7 health car e pr oviders to appeal any determinations made under section 376.2102.
8 3. The health carrier or utilization rev iew entity shall maintain an online portal
9 to allow health car e provi ders to access all prior authorization decisions, including
10 determinations made under section 376.2102. For health car e pr oviders subject to prior
11 authorizations, the portal shall include the status of each prior authorization r equest, all
12 notifications to the health care pr ovider , the dates the health care provi der r eceived such
13 notifications, and any other information r elevant to the determination.
376.2106. No health carrier or utilization revi ew entity shall deny or red uce
2 payment to a health care prov ider for a health car e service for which the prov ider has a
3 prior authorization unless the pr ovider:
4 (1) Knowingly and materially misrep res ented the health care service in a req uest
5 for payment submitted to the health carrier or utilization review entity with the specific
6 intent to deceive and obtain an unlawful payment fr om the carrier or entity; or
7 (2) Failed to substantially perform the health care service.
376.2108. 1. The pr ovisions of sections 376.2100 to 376.2108 shall not apply to
2 MO HealthNet, except that a Medicaid managed car e organization as defined in section
3 208.431 shall be consider ed a health carrier for purposes of sections 376.2100 to
4 376.2108.
5 2. The pro visions of sections 376.2100 to 376.2108 shall not apply to health car e
6 pr oviders who have not participated in a health benefit plan offer ed by the health
7 carrier for at least one full evaluation period.
8 3. Nothing in sections 376.2100 to 376.2108 shall be construed to:
9 (1) Authorize a health car e pr ovider to pr ovide a health care service outside the
10 scope of his or her applicable license; or
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11 (2) Require a health carrier or utilization review entity to pay for a health car e
12 service described in subdivision (1) of this subsection.
✔
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