Vermont Statutes Title 18 Sec. 9418b
Terms Used In Vermont Statutes Title 18 Sec. 9418b
- Board: means the Green Mountain Care Board established in chapter 220 of this title. See
- Claim: means any claim, bill, or request for payment for all or any portion of provided health care services that is submitted by:
- Commissioner: means the Commissioner of Financial Regulation or the Commissioner's designee. See
- Department: means the Department of Financial Regulation. See
- following: when used by way of reference to a section of the law shall mean the next preceding or following section. See
- Fraud: Intentional deception resulting in injury to another.
- Health care facility: means all institutions, whether public or private, proprietary or nonprofit, which offer diagnosis, treatment, inpatient, or ambulatory care to two or more unrelated persons, and the buildings in which those services are offered. See
- Health care provider: means a person, partnership, or corporation, other than a facility or institution, licensed or certified or authorized by law to provide professional health care service in this State to an individual during that individual's medical care, treatment, or confinement. See
- Health insurer: means any health insurance company, nonprofit hospital and medical service corporation, managed care organizations, and, to the extent permitted under federal law, any administrator of an insured, self-insured, or publicly funded health care benefit plan offered by public and private entities. See
- Health plan: means a health insurer, disability insurer, health maintenance organization, medical or hospital service corporation, and, to the extent permitted under federal law, any administrator of an insured or self-insured plan. See
- Insured: means any person eligible for health care benefits under a health benefit plan, and includes all of the following terms: enrollee, subscriber, member, insured, dependent, covered individual, and beneficiary. See
- prior authorization: includes preadmission review, pretreatment review, and utilization review. See
- provider: means a person, partnership, or corporation licensed, certified, or otherwise authorized by law to provide professional health care services in this State and shall include a health care provider group, network, independent practice association, or physician hospital organization that is acting exclusively as an administrator on behalf of a health care provider to facilitate the provider's participation in health care contracts. See
- State: when applied to the different parts of the United States may apply to the District of Columbia and any territory and the Commonwealth of Puerto Rico. See
§ 9418b. Prior authorization
(a) Health plans shall pay claims for health care services for which prior authorization was required by and received from the health plan, unless:
(1) the insured was not a covered individual at the time the service was rendered;
(2) the insured’s benefit limitations were exhausted;
(3) the prior authorization was based on materially inaccurate information from the health care provider;
(4) the health plan has a reasonable belief that fraud or other intentional misconduct has occurred; or
(5) the health plan determines through coordination of benefits that another health insurer is liable for the claim.
(b) Notwithstanding the provisions of subsection (a) of this section, nothing in this section shall be construed to prohibit a health plan from denying continued or extended coverage as part of concurrent review, denying a claim if the health plan is not primarily obligated to pay the claim, or applying payment policies that are consistent with an applicable law, rule, or regulation.
(c) A health plan shall furnish, upon request from a health care provider, a current list of services and supplies requiring prior authorization.
(d) A health plan shall post a current list of services and supplies requiring prior authorization to the insurer’s website.
(e) In addition to any other remedy provided by law, if the Commissioner finds that a health plan has engaged in a pattern and practice of violating this section, the Commissioner may impose an administrative penalty against the health plan of no more than $500.00 for each violation, and may order the health plan to cease and desist from further violations and order the health plan to remediate the violation. In determining the amount of penalty to be assessed, the Commissioner shall consider the following factors:
(1) the appropriateness of the penalty with respect to the financial resources and good faith of the health plan;
(2) the gravity of the violation or practice;
(3) the history of previous violations or practices of a similar nature;
(4) the economic benefit derived by the health plan and the economic impact on the health care facility or health care provider resulting from the violation; and
(5) any other relevant factors.
(f) Nothing in this section shall be construed to prohibit a health plan from applying payment policies that are consistent with applicable federal or State laws and regulations, or to relieve a health plan from complying with payment standards established by federal or State laws and regulations.
(g)(1)(A) Notwithstanding any provision of law to the contrary, on and after March 1, 2014, when requiring prior authorization for prescription drugs, medical procedures, and medical tests, a health plan shall accept for each prior authorization request either:
(i) the national standard transaction information, such as HIPAA 278 standards, for sending or receiving authorizations electronically; or
(ii) a uniform prior authorization form developed pursuant to subdivisions (2) and (3) of this subsection (g).
(B) A health plan shall have the capability to accept both the national standard transaction information and the uniform prior authorization forms developed pursuant to subdivisions (2) and (3) of this subsection (g).
(2)(A) Not later than September 1, 2013, the Department of Financial Regulation shall develop a clear, uniform, and readily accessible prior authorization form for prior authorization requests for medical procedures and medical tests.
(B) Not later than September 1, 2013, the Department of Financial Regulation shall develop clear, uniform, and readily accessible forms for prior authorization requests for prescription drugs after determining the appropriate number of forms.
(3) Each uniform prior authorization form developed pursuant to subdivision (2) of this subsection shall meet the following criteria, where applicable:
(A) The form shall include the core set of common data requirements for nonclinical information for prior authorization included in the HIPAA 278 standard transaction, national standards for prior authorization and electronic prescriptions, or both. The Department shall revise the form as needed to ensure that national standards are adopted and incorporated as soon as such standards are available and final.
(B) The form shall be made available electronically by the Department and by the health plan.
(C) The completed form or its data elements may be submitted electronically from the prescribing health care provider to the health plan.
(D) The Department shall develop the form in consultation with the Department of Vermont Health Access and with input from interested parties from at least one public meeting.
(E) The Department shall consider input on the proposed form from the national ASC X-12 workgroup, if available.
(F) In developing the uniform prior authorization forms, the Department shall take into consideration the following:
(i) existing prior authorization forms established by the federal Centers for Medicare and Medicaid Services, by the Department of Vermont Health Access, and by insurance and Medicaid departments and agencies in other states; and
(ii) national standards related to electronic prior authorization.
(4) A health plan shall respond to a completed prior authorization request from a prescribing health care provider within 48 hours after receipt for urgent requests and within two business days after receipt for non-urgent requests. The health plan shall notify a health care provider of or make available to a health care provider a receipt of the request for prior authorization and any needed missing information within 24 hours after receipt. If a health plan does not, within the time limits set forth in this section, respond to a completed prior authorization request, acknowledge receipt of the request for prior authorization, or request missing information, the prior authorization request shall be deemed to have been granted.
(h)(1) A health plan shall review the list of medical procedures and medical tests for which it requires prior authorization at least annually and shall eliminate the prior authorization requirements for those procedures and tests for which such a requirement is no longer justified or for which requests are routinely approved with such frequency as to demonstrate that the prior authorization requirement does not promote health care quality or reduce health care spending to a degree sufficient to justify the administrative costs to the plan.
(2) A health plan shall attest to the Department of Financial Regulation and the Green Mountain Care Board annually on or before September 15 that it has completed the review and appropriate elimination of prior authorization requirements as required by subdivision (1) of this subsection. (Added 2007, No. 203 (Adj. Sess.), § 29, eff. June 10, 2008; amended 2009, No. 61, § 31; 2011, No. 171 (Adj. Sess.), § 11h; 2013, No. 79, § 5a, eff. June 7, 2013; 2015, No. 54, § 38; 2019, No. 140 (Adj. Sess.), § 8, eff. July 6, 2020; 2023, No. 6, § 232, eff. July 1, 2023.)