Health insurance; prior authorization for health care services.

Plain English Breakdown

The official source does not specify what happens if an insurance company fails to meet new response times or how systems will be implemented for high-performing providers.

Health Insurance Changes for Prior Authorization

This bill changes the response times for prior authorization requests and sets new rules about denying claims and downcoding.

What This Bill Does

• Decreases from 72 hours to 24 hours the time by which a health insurance company must respond to expedited requests for prior authorization of healthcare services, and decreases from seven days to five days the response time for standard requests.
• Prohibits insurance companies from denying claims for dental services if dentists call during business hours but cannot reach someone or are on hold for more than 15 minutes.
• Prevents insurance companies from downcoding a claim just because prior authorization was needed.
• Requires health insurance companies to establish systems that allow providers with high approval rates (at least 90 percent) to skip prior authorization for routine care.

Who It Names or Affects

• Health insurance companies
• Doctors and dentists who request prior authorizations
• Patients receiving healthcare services

Terms To Know

Prior authorization

A process where a health insurance company must approve certain medical treatments or procedures before they can be given.

Downcoding

Changing the payment code of a healthcare claim to a lower value, which means less money is paid for the service.

Limits and Unknowns

• The bill does not specify what happens if an insurance company fails to meet these new response times.
• It's unclear how insurance companies will implement systems that allow high-performing providers to skip prior authorization.

Official Summary Text

Health insurance;
prior authorization for health care services.
Decreases from 72 hours to 24 hours and from seven days to five days the time by which a health insurance carrier is required to respond to expedited and standard requests for prior authorization for health care services, respectively. The bill prohibits a carrier from (i) denying a claim for the provision of dental services by a dentist or oral surgeon for failure to obtain prior authorization if the dentist or oral surgeon calls the dental plan during business hours to obtain such prior authorization and is unable to reach the dental plan or is placed on hold for longer than 15 minutes and (ii) downcoding a claim if a prior authorization was approved. The bill requires carriers to establish a system in which providers with high prior authorization approval rates are not required to obtain prior authorization for routine health care services. Additionally, the bill provides that if a prior authorization request is denied, the carrier is required to notify providers and enrollees if artificial-intelligence based tools were used in reviewing the request.

Current Bill Text

SB 500

COMMERCE AND LABOR

1. Line 57, introduced, after
with

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high

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at least 90 percent