Revision: Nov. 19, 2023, 2:08 p.m.
2024 SESSION
24-3135.0
05/10
SENATE BILL [bill number]
AN ACT relative to prior authorizations for health care.
SPONSORS: [sponsors]
COMMITTEE: [committee]
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ANALYSIS
This bill establishes criteria for prior authorization required by insurers offering managed care health benefit plans.
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Explanation: Matter added to current law appears in bold italics.
Matter removed from current law appears [in brackets and struckthrough.]
Matter which is either (a) all new or (b) repealed and reenacted appears in regular type.
24-3135.0
05/10
STATE OF NEW HAMPSHIRE
In the Year of Our Lord Two Thousand Twenty Four
AN ACT relative to prior authorizations for health care.
Be it Enacted by the Senate and House of Representatives in General Court convened:
1 New Subdivision; Managed Care Law; Prior Authorization. Amend RSA 420-J by inserting after section 19 the following new subdivision:
Prior Authorization
420-J:20 Disclosure and Review of Prior Authorization Requirements.
I. A utilization review entity shall make any current prior authorization requirements and restrictions readily accessible on its website to enrollees, health care professionals, and the general public. This includes the written clinical criteria. Requirements shall be described in detail but also in easily understandable language.
II. If a utilization review entity intends either to implement a new prior authorization requirement or restriction, or amend an existing requirement or restriction, the utilization review entity shall:
(a) Ensure that the new or amended requirement is not implemented unless the utilization review entity's website has been updated to reflect the new or amended requirement or restriction.
(b) Provide contracted health care providers of enrollees written notice of the new or amended requirement or amendment no less than 60 days before the requirement or restriction is implemented.
III. Entities using prior authorization shall make statistics available regarding prior authorization approvals and denials on their website in a readily accessible format. The statistics shall include categories for:
(a) Provider specialty.
(b) Provider type.
(c) Medication or diagnostic test/procedure.
(d) Indication offered.
(e) Reason for denial.
(f) If appealed.
(g) If approved or denied on appeal;
(h) The time between submission and the response.
420-J:21 Personnel Qualified to Make Adverse Determinations. A utilization review entity shall ensure that all adverse determinations are made by a qualified provider. A qualified provider shall:
I. Possess a current and valid, non-restricted license to practice their specialty in the state of New Hampshire;
II. Be of the same specialty as the provider who typically manages the medical condition or disease or provides the health care service involved in the request;
III. Have experience treating patients with the medical condition or disease for which the health care service is being requested; and
IV. Make the adverse determination under the clinical direction of one of the utilization review entity's medical directors who is responsible for the provision of health care services provided to enrollees of New Hampshire. All such medical directors must be physicians licensed in New Hampshire.
420-J:22 Consultation Prior to Issuing an Adverse Determination. If a utilization review entity is questioning the medical necessity of a health care service, the utilization review entity shall notify the enrollee's provider that medical necessity is being questioned. Prior to issuing an adverse determination, the enrollee's provider must have the opportunity to discuss the medical necessity of the health care service on the telephone with the provider who will be responsible for determining authorization of the health care service under review.
420-J:23 Requirements Applicable to the Provider Who Can Review Appeals. The utilization entity shall ensure that all appeals are reviewed by a provider. The provider shall:
I. Possess a current and valid non-restricted license to practice their specialty in New Hampshire;
II. Have practiced in the same or similar specialty as provider who typically manages the medical condition or disease for at least 5 consecutive years;
III. Be knowledgeable of, and have experience providing, the health care services under appeal;
IV. Not be employed by a utilization review entity or be under contract with the utilization review entity other than to participate in one or more of the utilization review entity's health care provider networks or to perform reviews of appeals, or otherwise have any financial interest in the outcome of the appeal;
V. Not have been directly involved in making the adverse determination; and
VI. Consider all known clinical aspects of the health care service under review, including but not limited to, a review of all pertinent medical records provided to the utilization review entity by the enrollee's health care provider, any relevant records provided to the utilization review entity by a health care facility, and any medical literature provided to the utilization review entity by the health care provider.
420-J:24 Utilization Review Entity's Obligations with Respect to Prior Authorizations in Non-urgent Circumstances. If a utilization review entity requires prior authorization of a health care service, the utilization review entity shall make a prior authorization or adverse determination and notify the enrollee and the enrollee's health care provider of the prior authorization or adverse determination within 48 hours of obtaining all necessary information to make the prior authorization or adverse determination. For purposes of this section, "necessary information" includes the results of any face-to-face clinical evaluation or second opinion that may be required.
420-J:25 Utilization Review Entities' Obligations with Respect to Prior Authorizations Concerning Urgent Health Care Services. A utilization review entity shall render a prior authorization or adverse determination concerning urgent care services, and notify the enrollee and the enrollee's health care provider of that prior authorization or adverse determination not later than 24 hours after receiving all information needed to complete the review of the requested health care services.
420-J:26 Retrospective Denial.
I. The utilization review entity shall not revoke, limit, condition, or restrict a prior authorization if care is provided within 60 business days from the date the health care provider received the prior authorization.
II. A utilization review entity shall pay a health care provider at the contracted payment rate for a health care service provided by the health care provider per a prior authorization unless:
(a) The health care provider knowingly and materially misrepresented the health care service in the prior authorization request with the specific intent to deceive an obtain an unlawful payment from utilization review entity;
(b) The health care service was no longer a covered benefit on the day it was provided;
(c) The health care provider was no longer contracted with the patients' health insurance plan on the date the care was provided;
(d) The health care provider failed to meet the utilization review entity's timely filing requirements;
(e) The utilization review entity does not have liability for a claim; or
(f) The patient was no longer eligible for health care coverage on the day the care was provided.
420-J:27 Health Care Services Deemed Authorized if a Utilization Review Entity Fails to Comply with the Requirements of this Subdivision. Any failure by a utilization review entity to comply with the deadlines and other requirements specified in this subdivision shall result in any health care services subject to review to be automatically deemed authorized by the utilization review entity.
2 Effective Date. This act shall take effect January 1, 2025.