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As Introduced
136th
General Assembly
Regular
Session
H. B. No. 214
2025-2026
Representative Miller, K.
To
amend sections 1751.72, 3923.041, and 5160.34 and to enact section
5160.341 of the Revised Code
to
require the Medicaid program and certain health insurers to report
data about prior authorization requirements and to require an
exemption to such requirements for certain providers.
BE
IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO:
Section
1.
That
sections 1751.72, 3923.041, and 5160.34 be amended and section
5160.341 of the Revised Code be enacted to read as follows:
Sec.
1751.72.
(A)
As used in this section:
(1)
"Chronic condition" means a medical condition that has
persisted after reasonable efforts have been made to relieve or cure
its cause and has continued, either continuously or episodically, for
longer than six continuous months.
(2)
"Clinical peer" means a health care practitioner in the
same, or in a similar, specialty that typically manages the medical
condition, procedure, or treatment under review.
(3)
"Covered person" means a person receiving coverage for
health services under a policy, contract, or agreement issued by a
health insuring corporation.
(4)
"Emergency services" has the same meaning as in section
1753.28 of the Revised Code.
(5)
"Fraudulent or materially incorrect information" means any
type of intentional deception or misrepresentation made by a person
with the knowledge that the deception could result in some
unauthorized benefit to the covered person in question.
(6)
"Health care practitioner" has the same meaning as in
section 3701.74 of the Revised Code.
(7)
"NCPDP SCRIPT standard" means the national council for
prescription drug programs SCRIPT standard version 201310 or the most
recent standard adopted by the the United States department of health
and human services.
(8)
"Prior authorization requirement" means any practice
implemented by a health insuring corporation in which coverage of a
health care service, device, or drug is dependent upon a covered
person or a health care practitioner obtaining approval from the
health insuring corporation prior to the service, device, or drug
being performed, received, or prescribed, as applicable. "Prior
authorization" includes prospective or utilization review
procedures conducted prior to providing a health care service,
device, or drug.
(9)
"Urgent care services" means a medical care or other
service for a condition where application of the timeframe for making
routine or non-life threatening care determinations is either of the
following:
(a)
Could seriously jeopardize the life, health, or safety of the patient
or others due to the patient's psychological state;
(b)
In the opinion of a practitioner with knowledge of the patient's
medical or behavioral condition, would subject the patient to adverse
health consequences without the care or treatment that is the subject
of the request.
(10)
"Utilization review" and "utilization review
organization" have the same meanings as in section 1751.77 of
the Revised Code.
(B)
If a policy, contract, or agreement issued by a health insuring
corporation contains a prior authorization requirement, then all of
the following apply:
(1)
On or before January 1, 2018, the health insuring corporation shall
permit health care practitioners to access the prior authorization
form through the applicable electronic software system.
(2)(a)
For policies issued on or after January 1, 2018, the health insuring
corporation or other payer acting on behalf of the health insuring
corporation, shall accept prior authorization requests through a
secure electronic transmission.
(b)
For policies issued on or after January 1, 2018, the health insuring
corporation, a pharmacy benefit manager responsible for handling
prior authorization requests, or other payer acting on behalf of the
health insuring corporation shall accept and respond to prior
prescription benefit authorization requests through a secure
electronic transmission using NCPDP SCRIPT standard ePA transactions,
and for prior medical benefit authorization requests through a secure
electronic transmission using standards established by the council
for affordable quality health care on operating rules for information
exchange or its successor.
(c)
For purposes of division (B)(2) of this section, neither of the
following shall be considered a secure electronic transmission:
(i)
A facsimile;
(ii)
A proprietary payer portal for prescription drug requests that does
not use NCPDP SCRIPT standard.
(3)
For policies issued on or after January 1, 2018, a health care
practitioner and health insuring corporation may enter into a
contractual arrangement under which the health insuring corporation
agrees to process prior authorization requests that are not submitted
electronically because of the financial hardship that electronic
submission of prior authorization requests would create for the
health care practitioner or if internet connectivity is limited or
unavailable where the health care practitioner is located.
(4)(a)
For policies issued on or after January 1, 2018, if the health care
practitioner submits the request for prior authorization as described
in divisions (B)(1) and (2) of this section, the health insuring
corporation shall respond to all prior authorization requests within
forty-eight hours for urgent care services, or ten calendar days for
any prior authorization request that is not for an urgent care
service, of the time the request is received by the health insuring
corporation. Division (B)(4) of this section does not apply to
emergency services.
(b)
The response required under division (B)(4)(a) of this section shall
indicate whether the request is approved or denied. If the prior
authorization is denied, the health insuring corporation shall
provide the specific reason for the denial.
(c)
If the prior authorization request is incomplete, the health insuring
corporation shall indicate the specific additional information that
is required to process the request.
(5)(a)
For policies issued on or after January 1, 2018, if a health care
practitioner submits a prior authorization request as described in
divisions (B)(1) and (2) of this section, the health insuring
corporation shall provide an electronic receipt to the health care
practitioner acknowledging that the prior authorization request was
received.
(b)
For policies issued on or after January 1, 2018, if a health insuring
corporation requests additional information that is required to
process a prior authorization request as described in division
(B)(4)(c) of this section, the health care practitioner shall provide
an electronic receipt to the health insuring corporation
acknowledging that the request for additional information was
received.
(6)(a)
For policies issued on or after January 1, 2017, for a prior approval
related to a chronic condition, the health insuring corporation shall
honor a prior authorization approval for an approved drug for the
lesser of the following from the date of the approval:
(i)
Twelve months;
(ii)
The last day of the covered person's eligibility under the policy,
contract, or agreement.
(b)
The duration of all other prior authorization approvals shall be
dictated by the policy, contract, or agreement issued by the health
insuring corporation.
(c)
A health insuring corporation may, in relation to a prior approval
under division (B)(6)(a) of this section, require a health care
practitioner to submit information to the health insuring corporation
indicating that the patient's chronic condition has not changed.
(i)
The request for information by the health insuring corporation and
the response by the health care practitioner shall be in an
electronic format, which may be by electronic mail or other
electronic communication.
(ii)
The frequency of the submission of requested information shall be
consistent with medical or scientific evidence as defined in section
3922.01 of the Revised Code, but shall not be required more
frequently than quarterly.
(iii)
If the health care practitioner does not respond within five calendar
days from the date the request was received, the health insuring
corporation may terminate the twelve-month approval.
(d)
A twelve-month approval provided under division (B)(6)(a) of this
section is no longer valid and automatically terminates if there are
changes to federal or state laws or federal regulatory guidance or
compliance information prescribing that the drug in question is no
longer approved or safe for the intended purpose.
(e)
A twelve-month approval provided under division (B)(6)(a) of this
section does not apply to and is not required for any of the
following:
(i)
Medications that are prescribed for a non-maintenance condition;
(ii)
Medications that have a typical treatment of less than one year;
(iii)
Medications that require an initial trial period to determine
effectiveness and tolerability, beyond which a one-year, or greater,
prior authorization period will be given;
(iv)
Medications where there is medical or scientific evidence as defined
in section 3922.01 of the Revised Code that do not support a
twelve-month prior approval;
(v)
Medications that are a schedule I or II controlled substance or any
opioid analgesic or benzodiazepine, as defined in section 3719.01 of
the Revised Code;
(vi)
Medications that are not prescribed by an in-network provider as part
of a care management program.
(7)
For policies issued on or after January 1, 2017, a health insuring
corporation may, but is not required to, provide the twelve-month
approval prescribed in division (B)(6)(a) of this section for a
prescription drug that meets either of the following:
(a)
The drug is prescribed or administered to treat a rare medical
condition and pursuant to medical or scientific evidence as defined
in section 3922.01 of the Revised Code.
(b)
Medications that are controlled substances not included in division
(B)(6)(e)(v) of this section.
For
purposes of division (B)(7) of this section, "rare medical
condition" means any disease or condition that affects fewer
than two hundred thousand individuals in the United States.
(8)
Nothing in division (B)(6) or (7) of this section prohibits the
substitution, in accordance with section 4729.38 of the Revised Code,
of any drug that has received a twelve-month approval under division
(B)(6)(a) of this section when there is a release of either of the
following:
(a)
A United States food and drug administration approved comparable
brand product or a generic counterpart of a brand product that is
listed as therapeutically equivalent in the United States food and
drug administration's publication titled approved drug products with
therapeutic equivalence evaluations;
(b)
An interchangeable biological product, as defined in section 3715.01
of the Revised Code.
(9)(a)
For policies issued on or after January 1, 2017, upon written
request, a health insuring corporation shall permit a retrospective
review for a claim that is submitted for a service where prior
authorization was required but not obtained if the service in
question meets all of the following:
(i)
The service is directly related to another service for which prior
approval has already been obtained and that has already been
performed.
(ii)
The new service was not known to be needed at the time the original
prior authorized service was performed.
(iii)
The need for the new service was revealed at the time the original
authorized service was performed.
(b)
Once the written request and all necessary information is received,
the health insuring corporation shall review the claim for coverage
and medical necessity. The health insuring corporation shall not deny
a claim for such a new service based solely on the fact that a prior
authorization approval was not received for the new service in
question.
(10)(a)
For policies issued on or after January 1, 2017, the health insuring
corporation shall disclose to all participating health care
practitioners any new prior authorization requirement at least thirty
days prior to the effective date of the new requirement.
(b)
The notice may be sent via electronic mail or standard mail and shall
be conspicuously entitled "Notice of Changes to Prior
Authorization Requirements." The notice is not required to
contain a complete listing of all changes made to the prior
authorization requirements, but shall include specific information on
where the health care practitioner may locate the information on the
health insuring corporation's web site or, if applicable, the health
insuring corporation's portal.
(c)
All participating health care practitioners shall promptly notify the
health insuring corporation of any changes to the health care
practitioner's electronic mail or standard mail address.
(11)(a)
For policies issued on or after January 1, 2017, the health insuring
corporation shall make available to all participating health care
practitioners on its web site or provider portal a listing of its
prior authorization requirements, including specific information or
documentation that a practitioner must submit in order for the prior
authorization request to be considered complete.
(b)
The health insuring corporation shall make available on its web site
information about the policies, contracts, or agreements offered by
the health insuring corporation that clearly identifies specific
services, drugs, or devices to which a prior authorization
requirement exists.
(12)
For policies issued on or after January 1, 2018, the health insuring
corporation shall establish a streamlined appeal process relating to
adverse prior authorization determinations that shall include all of
the following:
(a)
For urgent care services, the appeal shall be considered within
forty-eight hours after the health insuring corporation receives the
appeal.
(b)
For all other matters, the appeal shall be considered within ten
calendar days after the health insuring corporation receives the
appeal.
(c)
The appeal shall be between the health care practitioner requesting
the service in question and a clinical peer.
(d)
If the appeal does not resolve the disagreement, either the covered
person or an authorized representative as defined in section 3922.01
of the Revised Code may request an external review under Chapter
3922. of the Revised Code to the extent Chapter 3922. of the Revised
Code is applicable.
(13)(a)
For policies issued on or after January 1, 2027, the health insuring
corporation shall make prior authorization data from the previous
calendar year available to all participating health care
practitioners in aggregate form for all services, drugs, or devices
for which prior authorization is required, including all of the
following:
(i)
The percentage of standard and expedited prior authorization requests
that were approved, denied, and approved after appeal;
(ii)
The percentage of prior authorization requests for which the
timeframe for review was extended;
(iii)
The average and median time that elapsed between the submission of a
prior authorization request and issuance of a decision by the health
insuring corporation for standard and expedited requests.
(b)
The health insuring corporation shall ensure that no later than the
last day of March each year, beginning in 2027, the data described in
division (B)(13)(a) of this section is both:
(i)
Made available on the health insuring corporation's web site or
provider portal;
(ii)
Compiled into a report and submitted to the department of insurance.
(c)
The department shall publish each report received under division
(B)(13)(b)(ii) of this section on department's web site and submit it
to the general assembly in accordance with section 101.68 of the
Revised Code.
(14)(a)
For policies issued on or after January 1, 2027, the health insuring
corporation shall not require a health care provider or health care
provider group to comply with a prior authorization requirement for a
health care service, medical device, or drug if both of the following
apply:
(i)
The health insuring corporation approved, or would have approved, at
least ninety per cent of the prior authorization requests submitted
by the health care provider or health care provider group for that
service, device, or drug during the preceding twelve months;
(ii)
The health care provider or health care provider group submitted at
least twenty prior authorization requests for the service, device, or
drug to the health insuring corporation during the preceding twelve
months.
(b)
The health insuring corporation shall provide the exemption required
by division (B)(14) of this section for a period not less than twelve
months. Nothing in division (B)(14) of this section shall be
construed as prohibiting a health insuring corporation from providing
such an exemption for a period exceeding twelve months.
(c)
A health care provider or health care provider group that does not
receive an exemption under division (B)(14) of this section may
request that the health insuring corporation provide evidence to the
provider or provider group supporting the health insuring
corporation's decision to not grant an exemption. The health care
provider or health care provider group shall not make more than one
request under division (B)(14)(c) of this section for the same
service, device, or drug in the same calendar year. The health
insuring corporation comply with such a request.
(d)
A health care provider or health care provider group may appeal the
health insuring corporation's decision to deny an exemption under
division (B)(14) of this section.
(e)
The health insuring corporation shall not require a health care
provider or health care provider group to request an exemption under
division (B)(14) of this section.
(f)
The health insuring corporation shall not deny or reduce payment for
a service, device, or drug that is provided without prior
authorization pursuant to an exemption granted under division (B)(14)
of this section on the sole basis that the service, device, or drug
was provided by or supervised by a health care provider or health
care provider group that is different than the provider or provider
group that requested the exemption. Division (B)(14)(f) of this
section does not apply if the providing or supervising provider or
provider group does either of the following:
(i)
Knowingly and materially misrepresents the service, device, or drug
provided in the request for payment with the intent to obtain an
unlawful payment amount from the health insuring corporation;
(ii)
Fails to substantially perform the service or to provide the device
or drug.
(g)
The health insuring corporation shall notify the health care provider
or health care provider group in writing when the health insuring
corporation grants an exemption under division (B)(14) of this
section for a service, device, or drug. The notice must include all
of the following information:
(i)
A statement that the health care provider or health care provider
group qualifies for an exemption to a prior authorization
requirement;
(ii)
The service, device, or drug to which the exemption applies;
(iii)
The dates the exemption begins and ends.
(h)(i)
At the end of the exemption period, the health insuring corporation
may evaluate the exemption granted under division (B)(14) of this
section.
(ii)
In conducting such an evaluation, the health insuring corporation
shall review twenty claims submitted to the health insuring
corporation in the preceding three months, selected at random, for
the service, device, or drug in question. If there are not twenty
relevant claims in the preceding three months, the health insuring
corporation may review claims submitted earlier.
(iii)
If less than ninety per cent of the reviewed claims would have been
approved based on medical necessity, then the health insuring
corporation may revoke the exemption. A health insuring corporation
that revokes an exemption shall provide the health care provider or
health care provider group with the information the health insuring
corporation relied upon in revoking the exemption and a plain
language explanation of how to appeal the revocation.
(iv)
A health insuring corporation shall not evaluate a health care
provider's or health care provider group's exemption relating to a
particular service, device, or drug more than once every twelve
months.
(v)
Nothing in division (B)(14) of this section shall be construed as
requiring health insuring corporation to evaluate an existing prior
authorization exemption.
(i)
If an exemption under division (B)(14) of this section is revoked by
the health insuring corporation and that revocation is not appealed,
the exemption remains in effect for thirty days following the date
the health insuring corporation notifies the health care provider or
health care provider group of the revocation.
(j)
A health care provider or health care provider group may appeal the
revocation of an exemption under division (B)(14) of this section
within thirty days after receiving notification of the revocation. If
the provider or provider group appeals a revocation and the
revocation is upheld, the exemption remains in effect for five days
after the date the revocation is upheld.
(k)
The health insuring corporation shall not revoke or deny an exemption
under division (B)(14) of this section unless a health care provider
licensed in this state who practices the same or a similar specialty
as the health care provider or health care provider group at issue,
and who has experience in providing the service, device, or drug at
issue, determines that the denial or revocation is warranted in
accordance with division (B)(14) of this section.
(l)
Nothing in division (B)(14) of this section shall be construed to
prohibit a health insuring corporation from making an administrative
denial of a claim.
(C)
For policies issued on or after January 1, 2017, except in cases of
fraudulent or materially incorrect information, a health insuring
corporation shall not retroactively deny a prior authorization for a
health care service, drug, or device when all of the following are
met:
(1)
The health care practitioner submits a prior authorization request to
the health insuring corporation for a health care service, drug, or
device.
(2)
The health insuring corporation approves the prior authorization
request after determining that all of the following are true:
(a)
The patient is eligible under the health benefit plan.
(b)
The health care service, drug, or device is covered under the
patient's health benefit plan.
(c)
The health care service, drug, or device meets the health insuring
corporation's standards for medical necessity and prior
authorization.
(3)
The health care practitioner renders the health care service, drug,
or device pursuant to the approved prior authorization request and
all of the terms and conditions of the health care practitioner's
contract with the health insuring corporation.
(4)
On the date the health care practitioner renders the prior approved
health care service, drug, or device, all of the following are true:
(a)
The patient is eligible under the health benefit plan.
(b)
The patient's condition or circumstances related to the patient's
care has not changed.
(c)
The health care practitioner submits an accurate claim that matches
the information submitted by the health care practitioner in the
approved prior authorization request.
(5)
If the health care practitioner submits a claim that includes an
unintentional error and the error results in a claim that does not
match the information originally submitted by the health care
practitioner in the approved prior authorization request, upon
receiving a denial of services from the health insuring corporation,
the health care practitioner may resubmit the claim pursuant to
division (C) of this section with the information that matches the
information included in the approved prior authorization.
(D)
Any provision of a contractual arrangement entered into between a
health insuring corporation and a health care practitioner or
beneficiary that is contrary to divisions (A) to (C) of this section
is unenforceable.
(E)
For policies issued on or after January 1, 2017, committing a series
of violations of this section that, taken together, constitute a
practice or pattern shall be considered an unfair and deceptive
practice under sections 3901.19 to 3901.26 of the Revised Code.
(F)
The superintendent of insurance may adopt rules in accordance with
Chapter 119. of the Revised Code as necessary to implement the
provisions of this section.
(G)
This section does not apply to any of the following types of
coverage: a policy, contract, certificate, or agreement that covers
only a specified accident, accident only, credit, dental, disability
income, long-term care, hospital indemnity, supplemental coverage as
described in section 3923.37 of the Revised Code, specified disease,
or vision care; a dental benefit that is offered as a part of a
policy, contract, certificate, or agreement offered by a health
insuring corporation; coverage issued as a supplement to liability
insurance; insurance arising out of workers' compensation or similar
law; automobile medical payment insurance; insurance under which
benefits are payable with or without regard to fault and which is
statutorily required to be contained in any liability insurance
policy or equivalent self-insurance; a medicare supplement policy of
insurance as defined by the superintendent of insurance by rule;
coverage under a plan through medicare or the federal employees
benefit program; or any coverage issued under Chapter 55 of Title 10
of the United States Code and any coverage issued as a supplement to
that coverage.
Sec.
3923.041.
(A)
As used in this section:
(1)
"Chronic condition" means a medical condition that has
persisted after reasonable efforts have been made to relieve or cure
its cause and has continued, either continuously or episodically, for
longer than six continuous months.
(2)
"Clinical peer" means a health care practitioner in the
same or in a similar, specialty that typically manages the medical
condition, procedure, or treatment under review.
(3)
"Covered person" means a person receiving coverage for
health services under a policy of sickness and accident insurance or
a public employee benefit plan.
(4)
"Emergency service" has the same meaning as in section
1753.28 of the Revised Code.
(5)
"Fraudulent or materially incorrect information" means any
type of intentional deception or misrepresentation made by a person
with the knowledge that the deception could result in some
unauthorized benefit to the covered person in question.
(6)
"Health care practitioner" has the same meaning as in
section 3701.74 of the Revised Code.
(7)
"NCPDP SCRIPT standard" means the national council for
prescription drug programs SCRIPT standard version 201310 or the most
recent standard adopted by the United States department of health and
human services.
(8)
"Prior authorization requirement" means any practice
implemented by either a sickness and accident insurer or a public
employee benefit plan in which coverage of a health care service,
device, or drug is dependent upon a covered person or a health care
practitioner obtaining approval from the insurer or plan prior to the
service, device, or drug being performed, received, or prescribed, as
applicable. "Prior authorization" includes prospective or
utilization review procedures conducted prior to providing a health
care service, device, or drug.
(9)
"Urgent care services" means a medical care or other
service for a condition where application of the timeframe for making
routine or non-life threatening care determinations is either of the
following:
(a)
Could seriously jeopardize the life, health, or safety of the patient
or others due to the patient's psychological state;
(b)
In the opinion of a practitioner with knowledge of the patient's
medical or behavioral condition, would subject the patient to adverse
health consequences without the care or treatment that is the subject
of the request.
(10)
"Utilization review" and "utilization review
organization" have the same meanings as in section 1751.77 of
the Revised Code.
(B)
If a policy issued by a sickness and accident insurer or a public
employee benefit plan contains a prior authorization requirement,
then all of the following apply:
(1)
For policies issued on or after January 1, 2018, the insurer or plan
shall permit health care practitioners to access the prior
authorization form through the applicable electronic software system.
(2)(a)
For policies issued on or after January 1, 2018, the insurer or plan,
or other payer acting on behalf of the insurer or plan, to accept
prior authorization requests through a secure electronic
transmission.
(b)
For policies issued on or after January 1, 2018, the insurer or plan,
a pharmacy benefit manager responsible for handling prior
authorization requests, or other payer acting on behalf of the
insurer or plan shall accept and respond to prior prescription
benefit authorization requests through a secure electronic
transmission using NCPDP SCRIPT standard ePA transactions, and for
prior medical benefit authorization requests through a secure
electronic transmission using standards established by the council
for affordable quality health care on operating rules for information
exchange or its successor.
(c)
For purposes of division (B)(2) of this section, neither of the
following shall be considered a secure electronic transmission:
(i)
A facsimile;
(ii)
A proprietary payer portal for prescription drug requests that does
not use NCPDP SCRIPT standard.
(3)
For policies issued on or after January 1, 2018, a health care
practitioner and an insurer or plan may enter into a contractual
arrangement under which the insurer or plan agrees to process prior
authorization requests that are not submitted electronically because
of the financial hardship that electronic submission of prior
authorization requests would create for the health care practitioner
or if internet connectivity is limited or unavailable where the
health care practitioner is located.
(4)(a)
For policies issued on or after January 1, 2018, if the health care
practitioner submits the request for prior authorization
electronically as described in divisions (B)(1) and (2) of this
section, the insurer or plan shall respond to all prior authorization
requests within forty-eight hours for urgent care services, or ten
calendar days for any prior authorization request that is not for an
urgent care service, of the time the request is received by the
insurer or plan. Division (B)(4) of this section does not apply to
emergency services.
(b)
The response required under division (B)(4)(a) of this section shall
indicate whether the request is approved or denied. If the prior
authorization is denied, the insurer or plan shall provide the
specific reason for the denial.
(c)
If the prior authorization request is incomplete, the insurer or plan
shall indicate the specific additional information that is required
to process the request.
(5)(a)
For policies issued on or after January 1, 2018, if a health care
practitioner submits a prior authorization request as described in
divisions (B)(1) and (2) of this section, the insurer or plan shall
provide an electronic receipt to the health care practitioner
acknowledging that the prior authorization request was received.
(b)
For policies issued on or after January 1, 2018, if an issuer or plan
requests additional information that is required to process a prior
authorization request as described in division (B)(4)(c) of this
section, the health care practitioner shall provide an electronic
receipt to the issuer or plan acknowledging that the request for
additional information was received.
(6)(a)
For policies issued on or after January 1, 2017, for a prior approval
related to a chronic condition, the insurer or plan shall honor a
prior authorization approval for an approved drug for the lesser of
the following from the date of the approval:
(i)
Twelve months;
(ii)
The last day of the covered person's eligibility under the policy or
plan.
(b)
The duration of all other prior authorization approvals shall be
dictated by the policy or plan.
(c)
An insurer or plan, in relation to prior approval under division
(B)(6)(a) of this section, may require a health care practitioner to
submit information to the insurer or plan indicating that the
patient's chronic condition has not changed.
(i)
The request for information by the insurer or plan and the response
by the health care practitioner shall be in an electronic format,
which may be by electronic mail or other electronic communication.
(ii)
The frequency of the submission of requested information shall be
consistent with medical or scientific evidence, as defined in section
3922.01 of the Revised Code, but shall not be required more
frequently than quarterly.
(iii)
If the health care practitioner does not respond within five calendar
days from the date the request was received, the insurer or plan may
terminate the twelve-month approval.
(d)
A twelve-month approval provided under division (B)(6)(a) of this
section is no longer valid and automatically terminates if there are
changes to federal or state laws or federal regulatory guidance or
compliance information prescribing that the drug in question is no
longer approved or safe for the intended purpose.
(e)
A twelve-month approval provided under division (B)(6)(a) of this
section does not apply to and is not required for any of the
following:
(i)
Medications that are prescribed for a non-maintenance condition;
(ii)
Medications that have a typical treatment of less than one year;
(iii)
Medications that require an initial trial period to determine
effectiveness and tolerability, beyond which a one-year, or greater,
prior authorization period will be given;
(iv)
Medications where there is medical or scientific evidence as defined
in section 3922.01 of the Revised Code that do not support a
twelve-month prior approval;
(v)
Medications that are a schedule I or II controlled substance or any
opioid analgesic or benzodiazepine, as defined in section 3719.01 of
the Revised Code;
(vi)
Medications that are not prescribed by an in-network provider as part
of the care management program.
(7)
For policies issued on or after January 1, 2017, an insurer or plan
may, but is not required to, provide the twelve-month approval
prescribed in division (B)(6)(a) of this section for a prescription
drug that meets either of the following:
(a)
The drug is prescribed or administered to treat a rare medical
condition and pursuant to medical or scientific evidence as defined
in section 3922.01 of the Revised Code.
(b)
Medications that are controlled substances not included in division
(B)(6)(e)(v) of this section.
For
purposes of division (B)(7) of this section, "rare medical
condition" means any disease or condition that affects fewer
than two hundred thousand individuals in the United States.
(8)
Nothing in division (B)(6) or (7) of this section prohibits the
substitution, in accordance with section 4729.38 of the Revised Code,
of any drug that has received a twelve-month approval under division
(B)(6)(a) of this section when there is a release of either of the
following:
(a)
A United States food and drug administration approved comparable
brand product or a generic counterpart of a brand product that is
listed as therapeutically equivalent in the United States food and
drug administration's publication titled approved drug products with
therapeutic equivalence evaluations;
(b)
An interchangeable biological product, as defined in section 3715.01
of the Revised Code.
(9)(a)
For policies issued on or after January 1, 2017, upon written
request, an insurer or plan shall permit a retrospective review for a
claim that is submitted for a service where prior authorization was
required but not obtained if the service in question meets all of the
following:
(i)
The service is directly related to another service for which prior
approval has already been obtained and that has already been
performed.
(ii)
The new service was not known to be needed at the time the original
prior authorized service was performed.
(iii)
The need for the new service was revealed at the time the original
authorized service was performed.
(b)
Once the written request and all necessary information is received,
the insurer or plan shall review the claim for coverage and medical
necessity. The insurer or plan shall not deny a claim for such a new
service based solely on the fact that a prior authorization approval
was not received for the new service in question.
(10)(a)
For policies issued on or after January 1, 2017, the insurer or plan
shall disclose to all participating health care practitioners any new
prior authorization requirement at least thirty days prior to the
effective date of the new requirement.
(b)
The notice may be sent via electronic mail or standard mail and shall
be conspicuously entitled "Notice of Changes to Prior
Authorization Requirements." The notice is not required to
contain a complete listing of all changes made to the prior
authorization requirements, but shall include specific information on
where the health care practitioner may locate the information on the
insurer or plan's web site or, if applicable, the insurer's or plan's
portal.
(c)
All participating health care practitioners shall promptly notify the
insurer or plan of any changes to the health care practitioner's
electronic mail or standard mail address.
(11)(a)
For policies issued on or after January 1, 2017, the insurer or plan
shall make available to all participating health care practitioners
on its web site or provider portal a listing of its prior
authorization requirements, including specific information or
documentation that a practitioner must submit in order for the prior
authorization request to be considered complete.
(b)
The insurer or plan shall make available on its web site information
about the policies, contracts, or agreements offered by the insurer
or plan that clearly identifies specific services, drugs, or devices
to which a prior authorization requirement exists.
(12)
For policies issued on or after January 1, 2018, the insurer or plan
shall establish a streamlined appeal process relating to adverse
prior authorization determinations that shall include all of the
following:
(a)
For urgent care services, the appeal shall be considered within
forty-eight hours after the insurer or plan receives the appeal.
(b)
For all other matters, the appeal shall be considered within ten
calendar days after the insurer or plan receives the appeal.
(c)
The appeal shall be between the health care practitioner requesting
the service in question and a clinical peer.
(d)
If the appeal does not resolve the disagreement, either the covered
person or an authorized representative as defined in section 3922.01
of the Revised Code may request an external review under Chapter
3922. of the Revised Code to the extent Chapter 3922. of the Revised
Code is applicable.
(13)(a)
For policies issued on or after January 1, 2027, the insurer or plan
shall make prior authorization data from the previous calendar year
available to all participating health care practitioners in aggregate
form for all services, drugs, or devices for which prior
authorization is required, including all of the following:
(i)
The percentage of standard and expedited prior authorization requests
that were approved, denied, and approved after appeal;
(ii)
The percentage of prior authorization requests for which the
timeframe for review was extended;
(iii)
The average and median time that elapsed between the submission of a
prior authorization request and issuance of a decision by the insurer
or plan for standard and expedited requests.
(b)
The insurer or plan shall ensure that no later than the last day of
March each year, beginning in 2027, the data described in division
(B)(13)(a) of this section is both:
(i)
Made available on the insurer's or plan's web site or provider
portal;
(ii)
Compiled into a report and submitted to the department of insurance.
(c)
The department shall publish each report received under division
(B)(13)(b)(ii) of this section on department's web site and submit it
to the general assembly in accordance with section 101.68 of the
Revised Code.
(14)(a)
For policies issued on or after January 1, 2027, the insurer or plan
shall not require a health care provider or health care provider
group to comply with a prior authorization requirement for a health
care service, medical device, or drug if both of the following apply:
(i)
The insurer or plan approved, or would have approved, at least ninety
per cent of the prior authorization requests submitted by the health
care provider or health care provider group for that service, device,
or drug during the preceding twelve months;
(ii)
The health care provider or health care provider group submitted at
least twenty prior authorization requests for the service, device, or
drug to the insurer or plan during the preceding twelve months.
(b)
The insurer or plan shall provide the exemption required by division
(B)(14) of this section for a period not less than twelve months.
Nothing in division (B)(14) of this section shall be construed as
prohibiting an insurer or plan from providing such an exemption for a
period exceeding twelve months.
(c)
A health care provider or health care provider group that does not
receive an exemption under division (B)(14) of this section may
request that the insurer or plan provide evidence to the provider or
provider group supporting the insurer's or plan's decision to not
grant an exemption. The health care provider or health care provider
group shall not make more than one request under division (B)(14)(c)
of this section for the same service, device, or drug in the same
calendar year. The insurer or plan shall comply with such a request.
(d)
A health care provider or health care provider group may appeal the
insurer's or plan's decision to deny an exemption under division
(B)(14) of this section.
(e)
The insurer or plan shall not require a health care provider or
health care provider group to request an exemption under division
(B)(14) of this section.
(f)
The insurer or plan shall not deny or reduce payment for a service,
device, or drug that is provided without prior authorization pursuant
to an exemption granted under division (B)(14) of this section on the
sole basis that the service, device, or drug was provided by or
supervised by a health care provider or health care provider group
that is different than the provider or provider group that requested
the exemption. Division (B)(14)(f) of this section does not apply if
the providing or supervising provider or provider group does either
of the following:
(i)
Knowingly and materially misrepresents the service, device, or drug
provided in the request for payment with the intent to obtain an
unlawful payment amount from the insurer or plan;
(ii)
Fails to substantially perform the service or to provide the device
or drug.
(g)
The insurer or plan shall notify the health care provider or health
care provider group in writing when the insurer or plan grants an
exemption under division (B)(14) of this section for a service,
device, or drug. The notice must include all of the following
information:
(i)
A statement that the health care provider or health care provider
group qualifies for an exemption to a prior authorization
requirement;
(ii)
The service, device, or drug to which the exemption applies;
(iii)
The dates the exemption begins and ends.
(h)(i)
At the end of the exemption period, the insurer or plan may evaluate
the exemption granted under division (B)(14) of this section.
(ii)
In conducting such an evaluation, the insurer or plan shall review
twenty claims submitted to the insurer or plan in the preceding three
months, selected at random, for the service, device, or drug in
question. If there are not twenty relevant claims in the preceding
three months, the insurer or plan may review claims submitted
earlier.
(iii)
If less than ninety per cent of the reviewed claims would have been
approved based on medical necessity, then the insurer or plan may
revoke the exemption. An insurer or plan that revokes an exemption
shall provide the health care provider or health care provider group
with the information the insurer or plan relied upon in revoking the
exemption and a plain language explanation of how to appeal the
revocation.
(iv)
An insurer or plan shall not evaluate a health care provider's or
health care provider group's exemption relating to a particular
service, device, or drug more than once every twelve months.
(v)
Nothing in division (B)(14) of this section shall be construed as
requiring an insurer or plan to evaluate an existing prior
authorization exemption.
(i)
If an exemption under division (B)(14) of this section is revoked by
the insurer or plan and that revocation is not appealed, the
exemption remains in effect for thirty days following the date the
insurer or plan notifies the health care provider or health care
provider group of the revocation.
(j)
A health care provider or health care provider group may appeal the
revocation of an exemption under division (B)(14) of this section
within thirty days after receiving notification of the revocation. If
the provider or provider group appeals a revocation and the
revocation is upheld, the exemption remains in effect for five days
after the date the revocation is upheld.
(k)
The insurer or plan shall not revoke or deny an exemption under
division (B)(14) of this section unless a health care provider
licensed in this state who practices the same or a similar specialty
as the health care provider or health care provider group at issue,
and who has experience in providing the service, device, or drug at
issue, determines that the denial or revocation is warranted in
accordance with division (B)(14) of this section.
(l)
Nothing in division (B)(14) of this section shall be construed to
prohibit an insurer or plan from making an administrative denial of a
claim.
(C)
For policies issued on or after January 1, 2017, except in cases of
fraudulent or materially incorrect information, an insurer or plan
shall not retroactively deny a prior authorization for a health care
service, drug, or device when all of the following are met:
(1)
The health care practitioner submits a prior authorization request to
the insurer or plan for a health care service, drug, or device;
(2)
The insurer or plan approves the prior authorization request after
determining that all of the following are true:
(a)
The patient is eligible under the health benefit plan.
(b)
The health care service, drug, or device is covered under the
patient's health benefit plan.
(c)
The health care service, drug, or device meets the insurer's or
plan's standards for medical necessity and prior authorization.
(3)
The health care practitioner renders the health care service, drug,
or device pursuant to the approved prior authorization request and
all of the terms and conditions of the health care practitioner's
contract with the insurer or plan;
(4)
On the date the health care practitioner renders the prior approved
health care service, drug, or device, all of the following are true:
(a)
The patient is eligible under the health benefit plan.
(b)
The patient's condition or circumstances related to the patient's
care has not changed.
(c)
The health care practitioner submits an accurate claim that matches
the information submitted by the health care practitioner in the
approved prior authorization request.
(5)
If the health care practitioner submits a claim that includes an
unintentional error and the error results in a claim that does not
match the information originally submitted by the health care
practitioner in the approved prior authorization request, upon
receiving a denial of services from the insurer or plan, the health
care practitioner may resubmit the claim pursuant to division (C) of
this section with the information that matches the information
included in the approved prior authorization.
(D)
Any provision of a contractual arrangement entered into between an
insurer or plan and a health care practitioner or beneficiary that is
contrary to divisions (A) to (C) of this section is unenforceable.
(E)
For policies issued on or after January 1, 2017, committing a series
of violations of this section that, taken together, constitute a
practice or pattern shall be considered an unfair and deceptive
practice under sections 3901.19 to 3901.26 of the Revised Code.
(F)
The superintendent of insurance may adopt rules in accordance with
Chapter 119. of the Revised Code as necessary to implement the
provisions of this section.
Notwithstanding any contrary provision of section 121.95 of the
Revised Code, a regulatory restriction contained in a rule adopted by
the superintendent to implement divisions (B)(13) and (14) of this
section is not subject to sections 121.95 to 121.953 of the Revised
Code.
(G)
This section does not apply to any of the following types of
coverage: a policy, contract, certificate, or agreement that covers
only a specified accident, accident only, credit, dental, disability
income, long-term care, hospital indemnity, supplemental coverage as
described in section 3923.37 of the Revised Code, specified disease,
or vision care; a dental benefit that is offered as a part of a
policy of sickness and accident insurance or a public employee
benefit plan; coverage issued as a supplement to liability insurance;
insurance arising out of workers' compensation or similar law;
automobile medical payment insurance; insurance under which benefits
are payable with or without regard to fault and which is statutorily
required to be contained in any liability insurance policy or
equivalent self-insurance; a medicare supplement policy of insurance
as defined by the superintendent of insurance by rule; coverage under
a plan through medicare or the federal employees benefit program; or
any coverage issued under Chapter 55 of Title 10 of the United States
Code and any coverage issued as a supplement to that coverage.
Sec.
5160.34.
(A)
As used in this section:
(1)
"Chronic condition" means a medical condition that has
persisted after reasonable efforts have been made to relieve or cure
its cause and has continued, either continuously or episodically, for
longer than six continuous months.
(2)
"Clinical peer" means a health care provider in the same,
or in a similar, specialty that typically manages the medical
condition, procedure, or treatment under review.
(3)
"Emergency services" has the same meaning as in section
1753.28 of the Revised Code.
(4)
"Prior authorization requirement" means any practice
implemented by a medical assistance program in which coverage of a
health care service, device, or drug is dependent upon a medical
assistance recipient or a health care provider, receiving approval
from the department of medicaid or its designee, including a medicaid
managed care organization, prior to the service, device, or drug
being performed, received, or prescribed, as applicable. "Prior
authorization" includes prospective or utilization review
procedures conducted prior to providing a health care service,
medical
device,
or drug.
(5)
"Urgent care services" means a medical care or other
service for a condition where application of the timeframe for making
routine or non-life threatening care determinations is either of the
following:
(a)
Could seriously jeopardize the life, health, or safety of the
recipient or others due to the recipient's psychological state;
(b)
In the opinion of a practitioner with knowledge of the recipient's
medical or behavioral condition, would subject the recipient to
adverse health consequences without the care or treatment that is the
subject of the request.
(6)
"Utilization review"
and
"utilization review organization" have
has
the
same
meanings
meaning
as
in section 1751.77 of the Revised Code.
(B)
If a medical assistance program has a prior authorization
requirement, the department of medicaid or its designee, including a
medicaid managed care organization, shall do all of the following:
(1)
On or before January 1, 2018, permit a health care provider to access
the prior authorization form through the applicable electronic
software system.
(2)(a)
On or before January 1, 2018, permit the department or its designee
to accept and respond to prior prescription benefit authorization
requests through a secure electronic transmission.
(b)
On or before January 1, 2018, the department or its designee shall
accept and respond to prior prescription benefit authorization
requests through a secure electronic transmission using NCPDP SCRIPT
standard ePA transactions, and for prior medical benefit
authorization requests through a secure electronic transmission using
standards established by the council for affordable quality health
care on operating rules for information exchange or its successor.
(c)
For purposes of division (B)(2) of this section, neither of the
following shall be considered a secure electronic transmission:
(i)
A facsimile;
(ii)
A proprietary payer portal for prescription drug requests that does
not use NCPDP SCRIPT standard.
(3)
On or before January 1, 2018, a health care provider and the
department of medicaid or its designee may enter into a contractual
arrangement under which the department or its designee agrees to
process prior authorization requests that are not submitted
electronically because of the financial hardship that electronic
submission of prior authorization requests would create for the
provider or if internet connectivity is limited or unavailable where
the provider is located.
(4)(a)
On or before January 1, 2018, if the health care provider submits the
request for prior authorization electronically as described in
divisions (B)(1) and (2) of this section,
the
department or its designee shall
respond
to all prior authorization requests within forty-eight hours for
urgent care services, or ten calendar days for any prior
authorization request that is not for an urgent care service, of the
time the request is received by the department or its designee.
Division (B)(4) of this section does not apply to emergency services.
(b)
The response required under division (B)(4)(a) of this section shall
indicate whether the request is approved or denied. If the prior
authorization is denied, the department or its designee shall provide
the specific reason for the denial.
(c)
If the prior authorization request is incomplete, the department or
its designee shall indicate the specific additional information that
is required to process the request.
(5)(a)
On or before January 1, 2018, if a health care provider submits a
prior authorization request as described in divisions (B)(1) and (2)
of this section, the department or its designee shall provide an
electronic receipt to the health care provider acknowledging that the
prior authorization request was received.
(b)
On or before January 1, 2018, if the department or its designee
requests additional information that is required to process a prior
authorization request as described in division (B)(4)(c) of this
section, the health care provider shall provide an electronic receipt
to the department or its designee acknowledging that the request for
additional information was received.
(6)(a)
On or before January 1, 2017, honor a prior authorization approval
for an approved drug for the lesser of the following from the date of
approval:
(i)
Twelve months;
(ii)
The last day of the medical assistance recipient's eligibility for
the medical assistance program.
(b)
The duration of all other prior authorization approvals shall be
dictated by the medical assistance program.
(c)
The department or its designee, in relation to prior approval under
division (B)(6)(a) of this section, may require a health care
provider to submit information to the department or its designee
indicating that the patient's chronic condition has not changed.
(i)
The request for information by the department or its designee and the
response by the health care provider shall be in an electronic
format, which may be by electronic mail or other electronic
communication.
(ii)
The frequency of the submission of requested information shall be
consistent with medical or scientific evidence as defined in section
3922.01 of the Revised Code, but shall not be required more
frequently than quarterly.
(iii)
If the health care provider does not respond within five calendar
days from the date the request was received, the insurer or plan may
terminate the twelve-month approval.
(d)
A twelve-month approval provided under division (B)(6)(a) of this
section is no longer valid and automatically terminates if there are
changes to federal or state laws or federal regulatory guidance or
compliance information prescribing that the drug in question is no
longer approved or safe for the intended purpose.
(e)
A twelve-month approval provided under division (B)(6)(a) of this
section does not apply to and is not required for any of the
following:
(i)
Medications that are prescribed for a non-maintenance condition;
(ii)
Medications that have a typical treatment of less than one year;
(iii)
Medications that require an initial trial period to determine
effectiveness and tolerability, beyond which a one-year, or greater,
prior authorization period will be given;
(iv)
Medications where there is medical or scientific evidence as defined
in section 3922.01 of the Revised Code that do not support a
twelve-month prior approval;
(v)
Medications that are a schedule I or II controlled substance or any
opioid analgesic or benzodiazepine, as defined in section 3719.01 of
the Revised Code;
(vi)
Medications that are not prescribed by an in-network provider as part
of a care management program.
(7)
On or before January 1, 2017, the department or its designee may, but
is not required to, provide the twelve-month approval prescribed in
division (B)(6)(a) of this section for a prescription drug that meets
either of the following:
(a)
The drug is prescribed or administered to treat a rare medical
condition and pursuant to medical or scientific evidence as defined
in section 3922.01 of the Revised Code.
(b)
Medications that are controlled substances not included in division
(B)(6)(e)(v) of this section.
For
purposes of division (B)(7) of this section, "rare medical
condition" means any disease or condition that affects fewer
than two-hundred thousand individuals in the United States.
(8)
Nothing in division (B)(6) or (7) of this section prohibits the
substitution, in accordance with section 4729.38 of the Revised Code,
of any drug that has received a twelve-month approval under division
(B)(6)(a) of this section when there is a release of either of the
following:
(a)
A United States food and drug administration approved comparable
brand product or a generic counterpart of a brand product that is
listed as therapeutically equivalent in the United States food and
drug administration's publication titled approved drug products with
therapeutic equivalence evaluations;
(b)
An interchangeable biological product, as defined in section 3715.01
of the Revised Code.
(9)(a)
On or after January 1, 2017, upon written request, the department or
its designee shall permit a retrospective review for a claim that is
submitted for a service where prior authorization was required, but
not obtained if the service in question meets all of the following:
(i)
The service is directly related to another service for which prior
approval has already been obtained and that has already been
performed.
(ii)
The new service was not known to be needed at the time the original
prior authorized service was performed.
(iii)
The need for the new service was revealed at the time the original
authorized service was performed.
(b)
Once the written request and all necessary information is received,
the department or its designee shall review the claim for coverage
and medical necessity. The department or its designee shall not deny
a claim for such a new service based solely on the fact that a prior
authorization approval was not received for the new service in
question.
(10)(a)
On or before January 1, 2017, disclose to all participating health
care providers any new prior authorization requirement at least
thirty days prior to the effective date of the new requirement.
(b)
The notice may be sent via electronic mail or standard mail and shall
be conspicuously entitled "Notice of Changes to Prior
Authorization Requirements." The notice is not required to
contain a complete listing of all changes made to the prior
authorization requirements, but shall include specific information on
where the health care provider may locate the information on the
department's or its designee's web site or, if applicable, the
department's or its designee's portal.
(c)
All participating health care providers shall promptly notify the
department or its designee of any changes to the health care
provider's electronic mail or standard mail address.
(11)(a)
On or before January 1, 2017, make available to all participating
health care providers on its web site or provider portal a listing of
its prior authorization requirements, including specific information
or documentation that a provider must submit in order for the prior
authorization request to be considered complete.
(b)
Make available on its web site information about the medical
assistance programs offered in this state that clearly identifies
specific services, drugs, or devices to which a prior authorization
requirement exists.
(12)
On or before January 1, 2018, establish a streamlined appeal process
relating to adverse prior authorization determinations that shall
include all of the following:
(a)
For urgent care services, the appeal shall be considered within
forty-eight hours after the department or its designee receives the
appeal.
(b)
For all other matters, the appeal shall be considered within ten
calendar days after the department or its designee receives the
appeal.
(c)
The appeal shall be between the health care provider requesting the
service in question and a clinical peer appointed by or contracted by
the department or the department's designee.
(d)
If the appeal does not resolve the disagreement, the appeal
procedures shall permit the recipient to further appeal in accordance
with section 5160.31 of the Revised Code.
(13)(a)
The department or the department's designee shall not require a
health care provider or health care provider group to comply with a
prior authorization requirement for a health care service, medical
device, or drug if both of the following criteria are met:
(i)
The department or its designee approved, or would have approved, at
least ninety per cent of the prior authorization requests submitted
by the health care provider or health care provider group for that
service, device, or drug during the preceding twelve months.
(ii)
The health care provider or health care provider group submitted at
least twenty prior authorization requests for that service, device,
or drug to the department or the department's designee during the
preceding twelve months.
(b)
The department or its designee shall provide the exemption required
by division (B)(13) of this section for a period not less than twelve
months. Nothing in division (B)(13) of this section shall be
construed as prohibiting the department or its designee from
providing such an exemption for a period exceeding twelve months.
(c)
A health care provider or health care provider group that does not
receive an exemption under division (B)(13) of this section may
request that the department or the department's designee provide
evidence to the provider or provider group supporting its decision to
not grant an exemption. The health care provider or health care
provider group shall not make more than one request under division
(B)(13)(c) of this section for the same service, device, or drug in a
calendar year. The department or department's designee shall comply
with such a request.
(d)
A health care provider or health care provider group may appeal the
department or designee's decision to deny an exemption.
(e)
The department or its designee shall not require a health care
provider or health care provider group to request an exemption
provided under division (B)(13) of this section;
(f)
The department or its designee shall not deny or reduce payment for a
service, device, or drug that is provided without prior authorization
pursuant to an exemption granted under division (B)(13) of this
section on the sole basis that the service, device, or drug was
provided by or supervised by a health care provider or health care
provider group that is different than the provider or provider group
that requested the exemption. This division does not apply if the
providing or supervising provider or provider group does either of
the following:
(i)
Knowingly and materially misrepresents the health care service,
device, or drug provided in its request for payment from the
department or the department's designee with the intent to obtain an
unlawful payment amount from the department or department's designee;
(ii)
Fails to substantially perform the health care service or to provide
the medical device or drug.
(g)
The department or its designee shall notify the health care provider
or health care provider group in writing when the insurer or plan
grants an exemption under division (B)(13) of this section for a
service, device, or drug. The notice shall include all of the
following information:
(i)
A statement that the health care provider or health care provider
group qualifies for an exemption to a prior authorization
requirement;
(ii)
The service, device, or drug to which the exemption applies;
(iii)
The dates the exemption will begin and end.
(h)(i)
At the end of the exemption period, the department or its designee
may evaluate an exemption it has granted under division (B)(13) of
this section.
(ii)
In conducting such an evaluation, the department or its designee
shall review twenty claims submitted to the department or its
designee in the preceding three months, selected at random, for the
service, device, or drug in question. If there are not twenty
relevant claims in the preceding three months, the department or its
designee may review claims submitted earlier.
(iii)
If less than ninety per cent of the reviewed claims would have been
approved based on medical necessity, then the department or its
designee may revoke the exemption. If the department or its designee
revokes an exemption, it shall provide the health care provider or
health care provider group with the information it relied upon in
making its determination and a plain language explanation of how to
appeal the revocation.
(iv)
The department or its designee shall not evaluate a health care
provider's or health care provider group's exemption relating to a
particular service, device, or drug more than once every twelve
months.
(v)
Nothing in division (B)(13) of this section shall be construed as
requiring the department or its designee to evaluate an existing
exemption.
(i)
If an exemption under division (B)(13) of this section is revoked by
the department or its designee and that revocation is not appealed,
the exemption remains in effect for thirty days following the date
the department or its designee notifies the health care provider or
health care provider group of the revocation.
(j)
A health care provider or health care provider group may appeal the
revocation of an exemption under division (B)(13) of this section
within thirty days after receiving notice of the revocation. If the
provider or provider group appeals the revocation and the revocation
is upheld, the exemption remains in effect for five days after the
date the revocation is upheld.
(k)
The department or its designee shall not revoke or deny an exemption
under division (B)(13) of this section unless a health care provider
licensed in this state who practices the same or a similar specialty
as the health care provider or health care provider group at issue,
and who has experience in providing the service, device, or drug at
issue, determines that the denial or revocation is warranted in
accordance with division (B)(13) of this section.
(l)
Nothing in division (B)(13) of this section shall be construed as
prohibiting the department or its designee from making an
administrative denial of a claim.
(C)
Beginning January 1, 2017, except in cases of fraudulent or
materially incorrect information, the department or its designee
shall not retroactively deny a prior authorization for a health care
service, drug, or device when all of the following are met:
(1)
The health care provider submits a prior authorization request to the
department or its designee for a health care service, drug, or
device.
(2)
The department or its designee approves the prior authorization
request after determining that all of the following are true:
(a)
The recipient is eligible for the health care service, drug, or
device under the medical assistance program.
(b)
The health care service, drug, or device is covered by the medical
assistance program.
(c)
The health care service, drug, or device meets the department's
standards for medical necessity and prior authorization.
(3)
The health care provider renders the health care service, drug, or
device pursuant to the approved prior authorization request and all
of the terms and conditions of the health care provider's contract
with the department or the department's designee.
(4)
On the date the health care provider renders the prior approved
health care service, drug, or device, all of the following are true:
(a)
The recipient is eligible for the medical assistance program.
(b)
The recipient's condition or circumstances related to the recipient's
care has not changed.
(c)
The health care provider submits an accurate claim that matches the
information submitted by the health care provider in the approved
prior authorization request.
(5)
If the health care provider submits a claim that includes an
unintentional error and the error results in a claim that does not
match the information originally submitted by the health care
provider in the approved prior authorization request, upon receiving
a denial of services from the department or its designee, the health
care provider may resubmit the claim pursuant to division (C) of this
section with the information that matches the information included in
the approved prior authorization.
(D)
Any provision of a contractual arrangement entered into between the
department or its designee and a health care provider or recipient
that is contrary to divisions (A) to (C) of this section is
unenforceable.
(E)
The director of medicaid may adopt rules in accordance with Chapter
119. of the Revised Code as necessary to implement the provisions of
this section.
Notwithstanding any contrary provision of section 121.95 of the
Revised Code, a regulatory restriction contained in a rule adopted by
the director to implement division (B)(13) of this section is not
subject to sections 121.95 to 121.953 of the Revised Code.
Sec.
5160.341.
(A)(1)
If a medical assistance program has a prior authorization requirement
for a health care service, medical device, or drug, the department or
its designee shall not require a health care provider or health care
provider group to comply with the requirement for that health care
service, device, or drug if both of the following criteria are met:
(a)
The department of medicaid or its designee approved or would have
approved at least ninety per cent of the prior authorization requests
submitted by the health care provider or health care provider group
for that service, device, or drug during the previous twelve-month
period.
(b)
The health care provider or health care provider group submitted at
least twenty prior authorization requests for that service, device,
or drug to the department or its designee during that twelve-month
period.
(2)
Such an exemption shall be provided for not less than twelve months.
(3)
Nothing in this section shall be construed as prohibiting the
department or its designee from establishing an exemption period of
more than twelve months.
(B)(1)
A health care provider or health care provider group that does not
receive an exemption under division (A) of this section may request
that the department or the department's designee provide evidence to
the provider or provider group supporting its decision to not grant
an exemption.
(2)
The health care provider or health care provider group may make such
a request at any time, but it may make not more than one such request
for the same service, device, or drug in a calendar year.
(3)
The department or its designee shall comply with such a request.
(C)
A health care provider or health care provider group may appeal the
department or its designee's decision to deny an exemption.
(D)
The department or its designee shall not do either of the following:
(1)
Require a health care provider or health care provider group to
request an exemption provided under division (A) of this section;
(2)
Deny or reduce payment for a health care service, medical device, or
drug that was provided without prior authorization pursuant to an
exemption granted under division (A) of this section on the sole
basis that the service, device, or drug was provided by or supervised
by a health care provider or health care provider group that is
different than the provider or provider group that requested the
exemption. This division does not apply if the providing or
supervising provider or provider group does either of the following:
(a)
Knowingly and materially misrepresents the health care service,
medical device, or drug provided in its request for payment from the
department or the department's designee with the intent to obtain an
unlawful payment amount from the department or its designee;
(b)
Fails to substantially perform the health care service or to provide
the medical device or drug.
(E)
When an exemption is granted under division (A) of this section for a
health care service, medical device, or drug, the department or its
designee shall notify the health care provider or health care
provider group in question. The notice shall include all of the
following information:
(1)
A statement that the health care provider or health care provider
group qualifies for an exemption to a prior authorization
requirement;
(2)
The health care service, medical device, or drug to which the
exemption applies;
(3)
The dates the exemption will begin and end.
(F)(1)
At the end of the exemption period, the department or its designee
may evaluate an exemption it has granted under division (A) of this
section.
(2)(a)
When conducting such an evaluation, the department or its designee
shall review twenty claims submitted to the department or its
designee, selected at random, for the health care service or medical
device in question.
(b)
The reviewed claims shall be from the immediately preceding three
months. If there are not twenty relevant claims in the preceding
three months, the department or its designee may review earlier
claims.
(3)(a)
If less than ninety per cent of the reviewed claims would have been
approved based on medical necessity, then the department or its
designee may revoke the exemption provided under division (A) of this
section.
(b)
If the department or its designee revokes an exemption, it shall
provide the health care provider or health care provider group with
both of the following:
(i)
The information it relied upon in making its determination;
(ii)
A plain language explanation of how to appeal the decision.
(4)
The department or its designee shall not evaluate a health care
provider's or health care provider group's exemption relating to a
particular service, device, or drug more than once every twelve
months.
(5)
Nothing in this section shall be construed as requiring the
department or its designee to evaluate an existing exemption.
(G)
If an exemption is revoked and not appealed, the exemption shall
remain in effect until thirty days after the date the department or
its designee notifies the health care provider or health care
provider group of the department or its designee's decision to revoke
the exemption.
(H)
A health care provider or health care provider group may appeal the
revocation of an exemption within thirty days of receiving notice of
the revocation. If the provider or provider group appeals the
revocation and the revocation is upheld, the exemption remains in
effect until five days after the date the revocation is upheld.
(I)
A decision to revoke or deny an exemption shall only be made by a
health care provider licensed in this state who practices the same or
a similar specialty as the health care provider or health care
provider group being considered for an exemption and who has
experience in providing the service, device, or drug to which the
exemption or potential exemption applies.
(J)
Nothing in this section shall be construed as prohibiting the
department or its designee from making an administrative denial of a
claim.
Section
2.
That
existing sections 1751.72, 3923.041, and 5160.34 of the Revised Code
are hereby repealed.