Read the full stored bill text
Wisconsin Legislature: SB1163: Bill Text
Skip navigation
Home
Documents
Senate
Assembly
Committees
Service Agencies
Docs
Options
Help
2025 Biennium
Statutes
Admin. Rules
Indices
Miscellaneous
Archives
Home
Bill, Rule, and Appointment Histories
Senators
Representatives
Committees
Text of Introduced Proposals
Amendment Text
Acts
Veto Messages
Enrolled Bills
Votes
Assembly and Senate Floor Calendars
Schedule of Committee Activities
Assembly and Senate Journals
Committee Records (ROCPs)
Legislative Rules
All Session-Related Documents
Subject Index to Acts
Subject Index to Legislation
Subject Index to Journals
Author Index to Legislation
Subject Index to Clearinghouse Rules
Miscellaneous Budget Documents
Executive Orders
Rulings of the Chair
Wisconsin Supreme Court Rules
Opinions of the Attorney General
Town Law Forms
Law
Districts
Session
Drafting Files
Feeds
Preferences
Show tree
Hide tree
Feedback
Help
Home
Senate Home
Senators
Committees
Session
Chief Clerk
Sergeant at Arms
Civics Education
Human Resources
Assembly Home
Representatives
Committees
Session
Chief Clerk
Sergeant at Arms
Human Resources
Schedule
Joint
Senate
Assembly
Study
Legislative Audit Bureau
Legislative Council
Legislative Fiscal Bureau
Legislative Human Resources Office
Legislative Reference Bureau
Legislative Technology Services Bureau
Menu
»
2025
»
Related Documents
»
Proposal Text
»
SB1163: Bill Text
Up
Up
2025 - 2026 LEGISLATURE
LRB-6501/1
EKL:cdc
2025 SENATE BILL 1163
March 19, 2026 - Introduced by Senators
Roys
,
Larson
,
Ratcliff
and
Smith
, cosponsored by Representatives
Prado
,
Clancy
,
Madison
,
McCarville
,
Sinicki
,
Tenorio
and
Subeck
. Referred to Committee on Insurance, Housing, Rural Issues and Forestry.
SB1163,1,4
1
An Act
to amend
40.51 (8), 40.51 (8m), 66.0137 (4), 120.13 (2) (g) and 185.983
2
(1) (intro.);
to create
609.815, 628.42 and 632.848 of the statutes;
relating to:
3
prior authorization transparency, exemptions from prior authorization
4
requirements, and granting rule-making authority.
Analysis by the Legislative Reference Bureau
This bill imposes several requirements on the use of prior authorization by health care plans. Under the bill, a health care plan must maintain a list of services for which prior authorization is required and publish the list on a website that is accessible to the general public without requiring users to create an account or input credentials. Each plan must also post on its website, or the website of a contracted utilization review organization, its current prior authorization requirements and restrictions in an accessible and conspicuous manner for enrollees and providers.
The bill provides that if a health care plan intends to impose or amend a prior authorization requirement or restriction, the plan must provide at least 60 days advanced written notice to providers. Further, a health care plan may not implement a new or amended prior authorization requirement or restriction unless the plan, or a contracted utilization review organization, has updated its website to reflect the change.
The bill also requires that clinical review criteria that a health care plan uses for prior authorization decisions meet certain conditions, including be based on nationally recognized, generally accepted standards, be developed in accordance with the current standards of a national medical accreditation entity, and ensure quality of care and access to needed health care services.
Further, the bill prohibits a health care plan from denying a claim for failure to obtain prior authorization if the prior authorization requirement was not in effect on the date that the service was provided. The bill also prohibits plans and contracted utilization review organizations from deeming supplies or services as incidental and from denying a claim for supplies or services if a provided health care service associated with the supplies or services receives, or does not require, prior authorization.
Finally, the bill allows the commissioner of insurance to establish, by rule, that a health insurance policy or self-insured health plan must exempt health care providers from obtaining prior authorization for a health care item or service for a period of time determined by the commissioner if, in the most recent evaluation period determined by the commissioner, the policy or plan has approved or would have approved not less than a specified proportion of prior authorization requests submitted by the provider for the item or service. Under the bill, the commissioner may specify the health care items or services subject to the exemption and how providers can obtain an exemption, including a process for automatic evaluation.
This proposal may contain a health insurance mandate requiring a social and financial impact report under s. 601.423, stats.
For further information see the state fiscal estimate, which will be printed as an appendix to this bill.
The people of the state of Wisconsin, represented in senate and assembly, do enact as follows:
SB1163,1
1
Section
1
.
40.51 (8) of the statutes is amended to read:
SB1163,2,6
2
40.51
(8)
Every health care coverage plan offered by the state under sub. (6)
3
shall comply with ss. 631.89, 631.90, 631.93 (2), 631.95, 632.72 (2), 632.722,
4
632.729, 632.746 (1) to (8) and (10), 632.747, 632.748, 632.798, 632.83, 632.835,
5
632.848,
632.85, 632.853, 632.855, 632.861, 632.867, 632.87 (3) to (6), 632.885,
6
632.89, 632.895 (5m) and (8) to (17), and 632.896.
SB1163,2
7
Section
2
.
40.51 (8m) of the statutes is amended to read:
SB1163,3,2
8
40.51
(8m)
Every health care coverage plan offered by the group insurance
9
board under sub. (7) shall comply with ss. 631.95, 632.722, 632.729, 632.746 (1) to
1
(8) and (10), 632.747, 632.748, 632.798, 632.83, 632.835,
632.848,
632.85, 632.853,
2
632.855, 632.861, 632.867, 632.885, 632.89, and 632.895 (11) to (17).
SB1163,3
3
Section
3
.
66.0137 (4) of the statutes is amended to read:
SB1163,3,10
4
66.0137
(4)
Self-insured health plans.
If a city, including a 1st class city,
5
or a village provides health care benefits under its home rule power, or if a town
6
provides health care benefits, to its officers and employees on a self-insured basis,
7
the self-insured plan shall comply with ss. 49.493 (3) (d), 631.89, 631.90, 631.93 (2),
8
632.722, 632.729, 632.746 (10) (a) 2. and (b) 2., 632.747 (3), 632.798,
632.848,
9
632.85, 632.853, 632.855, 632.861, 632.867, 632.87 (4) to (6), 632.885, 632.89,
10
632.895 (9) to (17), 632.896, and 767.513 (4).
SB1163,4
11
Section
4
.
120.13 (2) (g) of the statutes is amended to read:
SB1163,3,15
12
120.13
(2)
(g) Every self-insured plan under par. (b) shall comply with ss.
13
49.493 (3) (d), 631.89, 631.90, 631.93 (2), 632.722, 632.729, 632.746 (10) (a) 2. and
14
(b) 2., 632.747 (3), 632.798,
632.848,
632.85, 632.853, 632.855, 632.861, 632.867,
15
632.87 (4) to (6), 632.885, 632.89, 632.895 (9) to (17), 632.896, and 767.513 (4).
SB1163,5
16
Section
5
.
185.983 (1) (intro.) of the statutes is amended to read:
SB1163,3,24
17
185.983
(1)
(intro.) Every voluntary nonprofit health care plan operated by a
18
cooperative association organized under s. 185.981 shall be exempt from chs. 600 to
19
646, with the exception of ss. 601.04, 601.13, 601.31, 601.41, 601.42, 601.43, 601.44,
20
601.45, 611.26, 611.67, 619.04, 623.11, 623.12, 628.34 (10), 631.17, 631.89, 631.93,
21
631.95, 632.72 (2), 632.722, 632.729, 632.745 to 632.749, 632.775, 632.79, 632.795,
22
632.798,
632.848,
632.85, 632.853, 632.855, 632.861, 632.867, 632.87 (2) to (6),
23
632.885, 632.89, 632.895 (5) and (8) to (17), 632.896, and 632.897 (10) and chs. 609,
24
620, 630, 635, 645, and 646, but the sponsoring association shall:
SB1163,6
1
Section
6
.
609.815 of the statutes is created to read:
SB1163,4,4
2
609.815 Exemption from prior authorization requirements.
Limited
3
service health organizations, preferred provider plans, and defined network plans
4
are subject to any rules promulgated by the commissioner under s. 632.848.
SB1163,7
5
Section
7
.
628.42 of the statutes is created to read:
SB1163,4,7
6
628.42 Disclosure and review of prior authorization requirements.
7
(1)
In this section:
SB1163,4,8
8
(a) “Health care plan” has the meaning given in s. 628.36 (2) (a) 1.
SB1163,4,11
9
(b) 1. “Prior authorization” means the process by which a health care plan or
10
a contracted utilization review organization determines the medical necessity and
11
medical appropriateness of otherwise covered health care services.
SB1163,4,14
12
2. “Prior authorization” includes any requirement that an enrollee or provider
13
notify the health care plan or a contracted utilization review organization before, at
14
the time of, or concurrent to providing a health care service.
SB1163,4,15
15
(b) “Provider” has the meaning given in s. 628.36 (2) (a) 2.
SB1163,4,18
16
(2)
(a) A health care plan shall maintain a complete list of services for which
17
prior authorization is required, including services where prior authorization is
18
performed by an entity under contract with the health care plan.
SB1163,4,21
19
(b) A health care plan shall publish the list under par. (a) on its website. The
20
list shall be accessible by members of the general public without requiring the
21
creation of an account or the entry of any credentials or personal information.
SB1163,4,23
22
(c) The list under par. (a) is not required to contain any clinical review criteria
23
applicable to the services.
SB1163,5,7
24
(3)
(a) A health care plan shall make any current prior authorization
1
requirements and restrictions along with the clinical review criteria applicable to
2
those requirements or restrictions accessible and conspicuously posted on its
3
website to enrollees and providers. Content published by a 3rd party and licensed
4
for use by a health care plan or a contracted utilization review organization may
5
satisfy this subsection if it is available to access through the website of the health
6
care plan or the contracted utilization review organization as long as the website
7
does not unreasonably restrict access.
SB1163,5,10
8
(b) The prior authorization requirements and restrictions under par. (a) shall
9
be described in detail and shall be written in easily understandable, plain
10
language.
SB1163,5,13
11
(c) The prior authorization requirements and restrictions under par. (a) shall
12
indicate all of the following for each service subject to a prior authorization
13
requirement or restriction:
SB1163,5,15
14
1. When the requirement or restriction began for policies issued or delivered
15
in this state, including effective dates and any termination dates.
SB1163,5,17
16
2. The date that the requirement or restriction was listed on the website of the
17
health care plan or a contracted utilization review organization.
SB1163,5,18
18
3. The date that the requirement or restriction was removed in this state.
SB1163,5,20
19
4. A method to access a standardized electronic prior authorization request
20
transaction process.
SB1163,5,22
21
(4)
Any clinical review criteria on which a prior authorization requirement or
22
restriction is based shall satisfy all of the following:
SB1163,5,24
23
(a) The criteria are based on nationally recognized, generally accepted
24
standards except where provided by law.
SB1163,6,2
1
(b) The criteria are developed in accordance with the current standards of a
2
national medical accreditation entity.
SB1163,6,4
3
(c) The criteria ensure quality of care and access to needed health care
4
services.
SB1163,6,5
5
(d) The criteria are evidence-based.
SB1163,6,7
6
(e) The criteria are sufficiently flexible to allow deviations from current
7
standards when justified.
SB1163,6,9
8
(f) The criteria are evaluated and updated when necessary and no less
9
frequently than once every year.
SB1163,6,12
10
(5)
No health care plan may deny a claim for failure to obtain prior
11
authorization if the prior authorization requirement was not in effect on the date
12
that the service was provided.
SB1163,6,17
13
(6)
A health care plan or contracted utilization review organization may not
14
deem supplies or services as incidental or deny a claim for supplies or services if a
15
provided health care service associated with the supplies or services receives prior
16
authorization or if a provided health care service associated with the supplies or
17
services does not require prior authorization.
SB1163,7,5
18
(7)
If a health care plan intends to impose a new prior authorization
19
requirement or restriction or intends to amend a prior authorization requirement
20
or restriction, the health care plan shall provide all providers contracted with the
21
health care plan advanced written notice of the new or amended requirement or
22
restriction no less than 60 days before the new or amended requirement or
23
restriction is implemented. The advanced written notice may be provided in an
24
electronic format if the provider has agreed in advance to receive the notices
1
electronically. No health care plan may implement a new or amended prior
2
authorization requirement or restriction unless the health care plan or a contracted
3
utilization review organization has updated the information posted on
its website
4
required under sub. (3) to reflect the new or amended prior authorization
5
requirement or restriction.
SB1163,8
6
Section
8
.
632.848 of the statutes is created to read:
SB1163,7,8
7
632.848 Exemption from prior authorization requirements. (1)
In this
8
section:
Down
Down
/2025/related/proposals/sb1163
true
proposaltext
/2025/related/proposals/sb1163
proposaltext/2025/REG/SB1163
proposaltext/2025/REG/SB1163
section
true
Menu
»
2025
»
Related Documents
»
Proposal Text
»
SB1163: Bill Text
×
Details for
PDF view
Link
(Permanent link)
Bookmark this location
View toggle
Go to top of document
Search in this chapter
Search in this section
Search in this agency
Search in this chapter group
Search in this chapter
Search in this section
Cross references for section
Acts affecting this section
References to this
1970 Statutes Annotations
Appellate Court Citations
Administrative Code Index
Reference lines
Clear highlighting