Read the full stored bill text
SECOND REGULAR SESSION
HOUSE BILL NO. 1927
103RD GENERAL ASSEMBL Y
INTRODUCED BY REPRESENT A TIVE BUSH.
5005H.01I JOSEPH ENGLER, Chief Clerk
AN ACT
T o repeal section 376.1350, RSMo, and to enact in lieu thereof two new sections relating to
prior authorization of inpatient psychiatric hospital services.
Be it enacted by the General Assembly of the state of Missouri, as follows:
Section A. Section 376.1350, RSMo, is repealed and two new sections enacted in lieu
2 thereof, to be known as sections 376.1350 and 376.1368, to read as follows:
376.1350. For purposes of sections 376.1350 to [ 376.1390 ] 376.1389 , the following
2 terms mean:
3 (1) "Adverse determination", a determination by a health carrier or a utilization
4 review entity that an admission, availability of care, continued stay or other health care
5 service furnished or proposed to be furnished to an enrollee has been reviewed and, based
6 upon the information provided, does not meet the utilization review entity or health carrier's
7 requirements for medical necessity , appropriateness, health care setting, level of care or
8 ef fectiveness, or are experimental or investigational, and the payment for the requested
9 service is therefore denied, reduced or terminated;
10 (2) "Ambulatory review", utilization review of health care services performed or
11 provided in an outpatient setting;
12 (3) "Case management", a coordinated set of activities conducted for individual
13 patient management of serious, complicated, protracted or other health conditions;
14 (4) "Certification", a determination by a health carrier or a utilization review entity
15 that an admission, availability of care, continued stay or other health care service has been
16 reviewed and, based on the information provided, satisfies the health carrier's requirements
17 for medical necessity , appropriateness, health care setting, level of care and effective ness, and
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.
18 that payment will be made for that health care service provided the patient is an enrollee of
19 the health benefit plan at the time the service is provided;
20 (5) "Clinical peer", a physician or other health care professional who holds a
21 nonrestricted license in a state of the United States and in the same or similar specialty as
22 typically manages the medical condition, procedure or treatment under review;
23 (6) "Clinical review criteria", the written policies, written screening procedures, drug
24 formularies or lists of covered drugs, determination rules, decision abstracts, clinical
25 protocols, medical protocols, practice guidelines, and any other criteria or rationale used by
26 the health carrier or utilization review entity to determine the necessity and appropriateness of
27 health care services;
28 (7) "Concurrent review", utilization review conducted during a patient's hospital stay
29 or course of treatment;
30 (8) "Covered benefit" or "benefit", a health care service that an enrollee is entitled
31 under the terms of a health benefit plan;
32 (9) "Director", the director of the department of commerce and insurance;
33 (10) "Discharg e planning", the formal process for determining, prior to dischar ge
34 from a facility , the coordination and management of the care that a patient receives following
35 dischar ge from a facility;
36 (1 1) "Drug", any substance prescribed by a licensed health care provider acting within
37 the scope of the provider's license and that is intended for use in the diagnosis, mitigation,
38 treatment or prevention of disease. The term includes only those substances that are approved
39 by the FDA for at least one indication;
40 (12) "Emerg ency medical condition", the sudden and, at the time, unexpected onset of
41 a health condition that manifests itself by symptoms of suff icient severity , regardless of the
42 final diagnosis that is given, that would lead a prudent lay person, possessing an average
43 knowledge of medicine and health, to believe that immediate medical care is required, which
44 may include, but shall not be limited to:
45 (a) Placing the person's health in significant jeopardy;
46 (b) Serious impairment to a bodily function;
47 (c) Serious dysfunction of any bodily or gan or part;
48 (d) Inadequately controlled pain; or
49 (e) W ith respect to a pregnant woman who is having contractions:
50 a. That there is inadequate time to ef fect a safe transfer to another hospital before
51 delivery; or
52 b. That transfer to another hospital may pose a threat to the health or safety of the
53 woman or unborn child;
HB 1927 2
54 (13) "Emerge ncy service", a health care item or service furnished or required to
55 evaluate and treat an emer gency medical condition, which may include, but shall not be
56 limited to, health care services that are provided in a licensed hospital's emer gency facility by
57 an appropriate provider;
58 (14) "Enrollee", a policyholder , subscriber , covered person or other individual
59 participating in a health benefit plan;
60 (15) "FDA", the federal Food and Drug Administration;
61 (16) "Facility", an institution providing health care services or a health care setting,
62 including but not limited to hospitals and other licensed inpatient centers, ambulatory surgi cal
63 or treatment centers, skilled nursing centers, residential treatment centers, diagnostic,
64 laboratory and imaging centers, and rehabilitation and other therapeutic health settings;
65 (17) "Grievance", a written complaint submitted by or on behalf of an enrollee
66 regarding the:
67 (a) A vailability , delivery or quality of health care services, including a complaint
68 regarding an adverse determination made pursuant to utilization review;
69 (b) Claims payment, handling or reimbursement for health care services; or
70 (c) Matters pertaining to the contractual relationship between an enrollee and a health
71 carrier;
72 (18) "Health benefit plan", a policy , contract, certificate or agreement entered into,
73 of fered or issued by a health carrier to provide, deliver , arrange for , pay for , or reimburse any
74 of the costs of health care services; except that, health benefit plan shall not include any
75 coverage pursuant to liability insurance policy , workers' compensation insurance policy , or
76 medical payments insurance issued as a supplement to a liability policy;
77 (19) "Health care professional", a physician or other health care practitioner licensed,
78 accredited or certified by the state of Missouri to perform specified health services consistent
79 with state law;
80 (20) "Health care provider" or "provider", a health care professional or a facility;
81 (21) "Health care service", a service for the diagnosis, prevention, treatment, cure or
82 relief of a health condition, illness, injury or disease, including but not limited to the provision
83 of drugs or durable medical equipment;
84 (22) "Health carrier", an entity subject to the insurance laws and regulations of this
85 state that contracts or of fers to contract to provide, deliver , arrange for , pay for or reimburse
86 any of the costs of health care services, including a sickness and accident insurance company ,
87 a health maintenance or ganization, a nonprofit hospital and health service corporation, or any
88 other entity providing a plan of health insurance, health benefits or health services; except
89 that such plan shall not include any coverage pursuant to a liability insurance policy , workers'
HB 1927 3
90 compensation insurance policy , or medical payments insurance issued as a supplement to a
91 liability policy;
92 (23) "Health indemnity plan", a health benefit plan that is not a managed care plan;
93 (24) "Inpatient psychiatric hospital services", inpatient hospital services
94 furnished to an inpatient of a mental health facility , as defined in section 632.005, for
95 the tre atment of a mental disorder or mental illness, as such terms ar e defined in section
96 630.005;
97 (25) "Managed care plan", a health benefit plan that either requires an enrollee to use,
98 or creates incentives, including financial incentives, for an enrollee to use, health care
99 providers managed, owned, under contract with or employed by the health carrier;
100 [ (25) ] (26) "Participating provider", a provider who, under a contract with the health
101 carrier or with its contractor or subcontractor , has agreed to provide health care services to
102 enrollees with an expectation of receiving payment, other than coinsurance, co-payments or
103 deductibles, directly or indirectly from the health carrier;
104 [ (26) ] (27) "Peer -reviewed medical literature", a published scientific study in a
105 journal or other publication in which original manuscripts have been published only after
106 having been critically reviewed for scientific accuracy , validity and reliability by unbiased
107 independent experts, and that has been determined by the International Committee of Medical
108 Journal Editors to have met the uniform requirements for manuscripts submitted to
109 biomedical journals or is published in a journal specified by the United States Department of
110 Health and Human Services pursuant to Section 1861(t)(2)(B) of the Social Security Act (42
111 U.S.C. Section 1395x), as amended, as acceptable peer -reviewed medical literature. Peer -
112 reviewed medical literature shall not include publications or supplements to publications that
113 are sponsored to a significant extent by a pharmaceutical manufacturing company or health
114 carrier;
115 [ (27) ] (28) "Person", an individual, a corporation, a partnership, an association, a joint
116 venture, a joint stock company , a trust, an unincorporated or ganization, any similar entity or
117 any combination of the foregoing;
118 [ (28) ] (29) "Prior authorization", a certification made pursuant to a prior authorization
119 review , or notice as required by a health carrier or utilization review entity prior to the
120 provision of health care services;
121 [ (29) ] (30) "Prior authorization review", utilization review conducted prior to an
122 admission or a course of treatment, including but not limited to pre-admission review ,
123 pretreatment review , utilization review , and case management;
124 [ (30) ] (31) "Retrospective review", utilization review of medical necessity that is
125 conducted after services have been provided to a patient, but does not include the review of a
HB 1927 4
126 claim that is limited to an evaluation of reimbursement levels, veracity of documentation,
127 accuracy of coding or adjudication for payment;
128 [ (31) ] (32) "Second opinion", an opportunity or requirement to obtain a clinical
129 evaluation by a provider other than the one originally making a recommendation for a
130 proposed health service to assess the clinical necessity and appropriateness of the initial
131 proposed health service;
132 [ (32) ] (33) "Stabilize", with respect to an emer gency medical condition, that no
133 material deterioration of the condition is likely to result or occur before an individual may be
134 transferred;
135 [ (33) ] (34) "Standard reference compendia":
136 (a) The American Hospital Formulary Service-Drug Information; or
137 (b) The United States Pharmacopoeia-Drug Information;
138 [ (34) ] (35) "Utilization review", a set of formal techniques designed to monitor the
139 use of, or evaluate the clinical necessity , appropriateness, ef ficacy , or ef ficiency of, health
140 care services, procedures, or settings. T echniques may include ambulatory review , prior
141 authorization review , second opinion, certification, concurrent review , case management,
142 dischar ge planning or retrospective review . Utilization review shall not include elective
143 requests for clarification of coverage;
144 [ (35) ] (36) "Utilization review entity", a utilization review agent as defined in section
145 374.500, or an individual or entity that performs prior authorization reviews for a health
146 carrier or health care provider . A health carrier or health care provider is a utilization review
147 entity if it performs prior authorization review .
376.1368. A health carrier shall not requ ire prior authorization of inpatient
2 psychiatric hospital services.
✔
HB 1927 5