§1260.42. Documented prior authorization program; requirements

            A. A health insurance issuer that requires the satisfaction of a utilization review as a condition of payment of a claim submitted by a healthcare provider shall maintain a documented prior authorization program that utilizes evidence-based clinical review criteria. A health insurance issuer shall include a method for reviewing and updating clinical review criteria in its prior authorization program.

            B. If a health insurance issuer utilizes a third-party utilization review entity to perform utilization review, the health insurance issuer is responsible for ensuring that the requirements of this Subpart and applicable rules and regulations are met by the third-party utilization review entity.

            C. A health insurance issuer shall ensure that a prior authorization program meets the standards set forth by a national accreditation organization including but not limited to the National Committee for Quality Assurance, the Utilization Review Accreditation Commission, the Joint Commission, or the Accreditation Association for Ambulatory Health Care. A health insurance issuer or utilization review entity shall ensure that the utilization review program utilizes staff who are properly qualified, trained, supervised, and supported by explicit written, current clinical review criteria and review procedures.

            D. A health insurance issuer that requires utilization review for any service shall allow healthcare providers to submit a request for utilization review at any time, including outside of normal business hours. Within seventy-two hours of receiving an oral or written request of a healthcare provider, a health insurance issuer shall provide to the healthcare provider the specific clinical review criteria used by the health insurance issuer to make its utilization review determination for the specific item or service. A health insurance issuer’s referring of the provider to the specific criteria by electronic means is sufficient to meet the requirements of this Subsection.

            E.(1) A health insurance issuer shall maintain a system of documenting information and supporting clinical documentation submitted by healthcare providers seeking utilization review. A health insurance issuer shall maintain this information until the claim has been paid or the claim appeal process has been exhausted unless the information is otherwise required to be retained for a longer period of time by state or federal law or regulation.

            (2) A health insurance issuer shall provide a unique confirmation number to a healthcare provider upon receipt from that provider of a request for utilization review. Except as otherwise requested by the healthcare provider in writing, the unique confirmation number shall be communicated through the same medium through which the request for utilization review was made.

            (3) Upon request of the provider, a health insurance issuer or a utilization review entity shall remit to the provider written acknowledgment of receipt of each document submitted by a provider during the processing of a utilization review. This acknowledgment may be provided in electronic format.

            (4) When information is transmitted telephonically, a health insurance issuer shall provide written acknowledgment of the information communicated by the provider. This acknowledgment may be provided in electronic format.

            Acts 2023, No. 312, §1, eff. Jan. 1, 2024.