Utah Code 31A-22-650. Health care preauthorization requirements
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(1) As used in this section:
Terms Used In Utah Code 31A-22-650
- Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
- Contract: A legal written agreement that becomes binding when signed.
- Department: means the Insurance Department. See Utah Code 31A-1-301
- Enrollee: includes an insured. See Utah Code 31A-1-301
- Health care: means any of the following intended for use in the diagnosis, treatment, mitigation, or prevention of a human ailment or impairment:(83)(a) a professional service;(83)(b) a personal service;(83)(c) a facility;(83)(d) equipment;(83)(e) a device;(83)(f) supplies; or(83)(g) medicine. See Utah Code 31A-1-301
- health insurance: means insurance providing:
(84)(a)(i) a health care benefit; or(84)(a)(ii) payment of an incurred health care expense. See Utah Code 31A-1-301- Individual: means a natural person. See Utah Code 31A-1-301
- Insurance: includes :
(96)(b)(i) a risk distributing arrangement providing for compensation or replacement for damages or loss through the provision of a service or a benefit in kind;(96)(b)(ii) a contract of guaranty or suretyship entered into by the guarantor or surety as a business and not as merely incidental to a business transaction; and(96)(b)(iii) a plan in which the risk does not rest upon the person who makes an arrangement, but with a class of persons who have agreed to share the risk. See Utah Code 31A-1-301- Network provider: means a health care provider who has an agreement with a managed care organization to provide health care services to an enrollee with an expectation of receiving payment, other than coinsurance, copayments, or deductibles, directly from the managed care organization. See Utah Code 31A-1-301
- Plan year: means :
(149)(a) the year that is designated as the plan year in:(149)(a)(i) the plan document of a group health plan; or(149)(a)(ii) a summary plan description of a group health plan;(149)(b) if the plan document or summary plan description does not designate a plan year or there is no plan document or summary plan description:(149)(b)(i) the year used to determine deductibles or limits;(149)(b)(ii) the policy year, if the plan does not impose deductibles or limits on a yearly basis; or(149)(b)(iii) the employer's taxable year if:(149)(b)(iii)(A) the plan does not impose deductibles or limits on a yearly basis; and(149)(b)(iii)(B)(149)(b)(iii)(B)(I) the plan is not insured; or(149)(b)(iii)(B)(II) the insurance policy is not renewed on an annual basis; or(149)(c) in a case not described in Subsection (149)(a) or (b), the calendar year. See Utah Code 31A-1-301- Policy: includes a service contract issued by:
(150)(b)(i) a motor club under Chapter 11, Motor Clubs;(150)(b)(ii) a service contract provided under Chapter 6a, Service Contracts; and(150)(b)(iii) a corporation licensed under:(150)(b)(iii)(A) Chapter 7, Nonprofit Health Service Insurance Corporations; or(150)(b)(iii)(B) Chapter 8, Health Maintenance Organizations and Limited Health Plans. See Utah Code 31A-1-301- Process: means a writ or summons issued in the course of a judicial proceeding. See Utah Code 68-3-12.5
- State: when applied to the different parts of the United States, includes a state, district, or territory of the United States. See Utah Code 68-3-12.5
- United States: includes each state, district, and territory of the United States of America. See Utah Code 68-3-12.5
(1)(a) “Adverse preauthorization determination” means a determination by an insurer that health care does not meet the preauthorization requirement for the health care.(1)(b) “Authorization” means a determination by an insurer that for health care with a preauthorization requirement:(1)(b)(i) the proposed drug, device, or covered service meets all requirements, restrictions, limitations, and clinical criteria for authorization established by the insurer;(1)(b)(ii) the drug, device, or covered service is covered by the enrollee‘s insurance policy; and(1)(b)(iii) the insurer will provide coverage for the drug, device, or covered service subject to the provisions of the insurance policy, including any cost sharing responsibilities of the enrollee.(1)(c) “Device” means a prescription device as defined in Section 58-17b-102.(1)(d) “Drug” means the same as that term is defined in Section 58-17b-102.(1)(e) “Insurer” means the same as that term is defined in Section 31A-22-634.(1)(f) “Preauthorization requirement” means a requirement by an insurer that an enrollee obtain authorization for a drug, device, or service covered by the insurance policy, before receiving the drug, device, or service.(2)(2)(a) An insurer may not modify an existing requirement for authorization unless, at least 30 days before the day on which the modification takes effect, the insurer:(2)(a)(i) posts a notice of the modification on the website described in Subsection 31A-22-613.5(6)(a); and(2)(a)(ii) if requested by a network provider or the network provider’s representative, provides to the network provider by mail or email a written notice of modification to a particular requirement for authorization described in the request from the network provider.(2)(b) Subsection (2)(a) does not apply if:(2)(b)(i) complying with Subsection (2)(a) would create a danger to the enrollee’s health or safety; or(2)(b)(ii) the modification is for a newly covered drug or device.(2)(c) An insurer may not revoke an authorization for a drug, device, or covered service if:(2)(c)(i) the network provider submits a request for authorization for the drug, device, or covered service to the insurer;(2)(c)(ii) the insurer grants the authorization requested under Subsection (2)(c)(i);(2)(c)(iii) the network provider renders the drug, device, or covered service to the enrollee in accordance with the authorization and any terms and conditions of the network provider’s contract with the insurer;(2)(c)(iv) on the day on which the network provider renders the drug, device, or covered service to the enrollee:(2)(c)(iv)(A) the enrollee is eligible for coverage under the enrollee’s insurance policy; and(2)(c)(iv)(B) the enrollee’s condition or circumstances related to the enrollee’s care have not changed;(2)(c)(v) the network provider submits an accurate claim that matches the information in the request for authorization under Subsection (2)(c)(i); and(2)(c)(vi) the authorization was not based on fraudulent or materially incorrect information from the network provider.(3)(3)(a) An insurer that receives a request for authorization shall treat the request as a pre-service claim as defined in 29 C.F.R. § 2560.503-1 and process the request in accordance with:(3)(a)(i) 29 C.F.R. § 2560.503-1, regardless of whether the coverage is offered through an individual or group health insurance policy;(3)(a)(ii) Subsection 31A-4-116(2); and(3)(a)(iii) Section 31A-22-629.(3)(b) If a network provider submits a claim to an insurer that includes an unintentional error that results in a denial of the claim, the insurer shall permit the network provider with an opportunity to resubmit the claim with corrected information within a reasonable amount of time.(3)(c) Except as provided in Subsection (3)(d), the appeal of an adverse preauthorization determination regarding clinical or medical necessity as requested by a physician may only be reviewed by a physician who is currently licensed as a physician and surgeon in a state, district, or territory of the United States.(3)(d) The appeal of an adverse determination requested by a physician regarding clinical or medical necessity of a drug, may only be reviewed by an individual who is currently licensed in a state, district, or territory of the United States as:(3)(d)(i) a physician and surgeon; or(3)(d)(ii) a pharmacist.(3)(e) An insurer shall ensure that an adverse preauthorization determination regarding clinical or medical necessity is made by an individual who:(3)(e)(i) has knowledge of the medical condition or disease of the enrollee for whom the authorization is requested; or(3)(e)(ii) consults with a specialist who has knowledge of the medical condition or disease of the enrollee for whom the authorization is requested regarding the request before making the determination.(3)(f) An insurer shall specify how long an authorization is valid.(4)(4)(a) An insurer that removes a drug from the insurer’s formulary shall:(4)(a)(i) permit an enrollee, an enrollee’s designee, or an enrollee’s network provider to request an exemption from the change to the formulary for the purpose of providing the patient with continuity of care; and(4)(a)(ii) have a process to review and make a decision regarding an exemption requested under Subsection (4)(a)(i).(4)(b) If an insurer makes a change to the formulary for a drug in the middle of a plan year, the insurer may not implement the changes for an enrollee that is on an active course of treatment for the drug unless the insurer provides the enrollee with notice at least 30 days before the day on which the change is implemented.(5) Before April 1, 2021, and before April 1 of each year thereafter, an insurer with a preauthorization requirement shall report to the department, for the previous calendar year, the percentage of authorizations, not including a claim involving urgent care as defined in 29 C.F.R. § 2560.503-1, for which the insurer notified a provider regarding an authorization or adverse preauthorization determination more than one week after the day on which the insurer received the request for authorization.(6) An insurer may not have a preauthorization requirement for emergency health care as described in Section 31A-22-627. - health insurance: means insurance providing: