1 Prior Authorization Standards for Managed Care Plans. Amend RSA 420-E:4-b, VII to read as follows:

VII. Option to request a peer-to-peer review. When a utilization review entity requires prior authorization for an item or service, the utilization review entity shall offer the provider the opportunity to request a peer-to-peer review of a prior authorization request in which the provider is able to have a direct conversational exchange with a medical director or a designated provider who is a clinical peer about the basis for the prior authorization request. A "clinical peer" in this context shall be a health care professional who has demonstrable expertise to review a case, whether or not the reviewing professional is in the same or a similar specialty as the provider . The peer-to-peer review may be requested before the utilization review entity's prior authorization determination or after a prior authorization denial and before a formal grievance request has been made.The peer-to-peer review shall be made available by the utilization review entity within 2 business days of the request. If the peer-to-peer review is requested after a prior authorization denial, the utilization review entity shall treat the review request as a request for reconsideration that is external to the grievance process and shall provide the provider and the covered person a written determination containing a statement of the specific reasons for the reconsideration determination with reference to the information provided in the peer-to-peer review. The written reconsideration determination shall be provided within 7 business days of the peer-to-peer review.

2 New Paragraph; Prior Authorization Standards for Managed Care Plans; Peer-to-Peer Review. Amend RSA 420-E:4-b by inserting after paragraph VII the following new paragraph:

VII-a. Upon issuance of an adverse prior authorization determination, an insured or their provider may at any time request and receive a peer-to-peer review, including after an appeal has been initiated. The insurer shall honor such a request regardless of appeal status and schedule the peer-to-peer conversation within 5 business days of the request.

(a) The peer-to-peer review shall be conducted by a physician reviewer who:

(1) Holds an active license in the same or a similar specialty as the treating provider;

(2) Is actively practicing in the same or similar field of medicine; and

(3) Has expertise to assess the medical necessity of the specific procedure or service under review.

(b) In any peer-to-peer review conducted by an insurer, the insurer shall disclose to the requesting provider, at or before the start of the peer-to-peer conversation:

(1) The reviewer's full name;

(2) The reviewer's licensure type and issuing state; and

(3) The reviewer's National Provider Identifier (NPI). This disclosure requirement applies regardless of whether the call is initiated by the provider or the insurer.

(c) Failure of the insurer to comply with this section shall constitute an unfair insurance practice under RSA 417 and may be subject to administrative penalties by the insurance commissioner.

3 Utilization Review. Amend RSA 420-J:6, X to read as follows:

X. Option to request a peer-to-peer review. When a health carrier requires prior authorization for an item or service, the carrier shall offer the provider the opportunity to request a peer-to-peer review of a prior authorization request in which the provider is able to have a direct conversational exchange with a medical director or a designated provider who is a clinical peer about the basis for the prior authorization request. A "clinical peer" in this context shall be a health care professional who has demonstrable expertise to review a case, whether or not the reviewing professional is in the same or a similar specialty as the provider.The peer-to-peer review may be requested before the carrier's prior authorization determination or after a prior authorization denial and before a formal grievance request has been made.The peer-to-peer review shall be made available by the health carrier within 2 business days of the request. If the peer-to-peer review is requested after a prior authorization denial, the heath carrier shall treat the review request as a request for reconsideration that is external to the grievance process and shall provide the provider and the covered person a written determination containing a statement of the specific reasons for the reconsideration determination with reference to the information provided in the peer-to-peer review. The written reconsideration determination shall be provided within 7 business days of the peer-to-peer review.

4 New Paragraph; Utilization Review; Peer-to-Peer Review Requirements. Amend RSA 420-J:6 by inserting after paragraph X the following new paragraph:

X-a. Upon issuance of an adverse prior authorization determination, an insured or their provider may at any time request and receive a peer-to-peer review, including after an appeal has been initiated. The insurer shall honor such a request regardless of appeal status and schedule the peer-to-peer conversation within 5 business days of the request.

(a) The peer-to-peer review shall be conducted by a physician reviewer who:

(1) Holds an active license in the same or a similar specialty as the treating provider;

(2) Is actively practicing in the same or similar field of medicine; and

(3) Has expertise to assess the medical necessity of the specific procedure or service under review.

(b) In any peer-to-peer review conducted by an insurer, the insurer shall disclose to the requesting provider, at or before the start of the peer-to-peer conversation:

(1) The reviewer's full name;

(2) The reviewer's licensure type and issuing state; and

(3) The reviewer's National Provider Identifier (NPI). This disclosure requirement applies regardless of whether the call is initiated by the provider or the insurer.

(c) Failure of the insurer to comply with this section shall constitute an unfair insurance practice under RSA 417 and may be subject to administrative penalties by the insurance commissioner.

5 Effective Date. This act shall take effect January 1. 2027.

1 Prior Authorization Standards for Managed Care Plans. Amend RSA 420-E:4-b, VII to read as follows:

VII. Option to request a peer-to-peer review. When a utilization review entity requires prior authorization for an item or service, the utilization review entity shall offer the provider the opportunity to request a peer-to-peer review of a prior authorization request in which the provider is able to have a direct conversational exchange with a medical director or a designated provider who is a clinical peer about the basis for the prior authorization request. A "clinical peer" in this context shall meet the criteria established in subparagraph VII-a(a) . *The peer-to-peer review may be requested before the utilization review entity's prior authorization determination or after a prior authorization denial .* A claimant retains the right to a peer-to-peer review regardless of whether an appeal has been requested by or on behalf of the claimant. The peer-to-peer review shall be made available by the utilization review entity within 2 business days of the request. If the peer-to-peer review is requested after a prior authorization denial, the utilization review entity shall treat the review request as a request for reconsideration that is external to the grievance process and shall provide the provider and the covered person a written determination containing a statement of the specific reasons for the reconsideration determination with reference to the information provided in the peer-to-peer review. The written reconsideration determination shall be provided within 7 business days of the peer-to-peer review.

2 New Paragraph; Prior Authorization Standards for Managed Care Plans; Peer-to-Peer Review. Amend RSA 420-E:4-b by inserting after paragraph VII the following new paragraph:

VII-a. Upon issuance of an adverse prior authorization determination, an insured or their provider may at any time request and receive a peer-to-peer review, including after an appeal has been initiated. The insurer shall honor such a request regardless of appeal status and schedule the peer-to-peer conversation within 5 business days of the request.

(a) The peer-to-peer review shall be conducted by a physician reviewer who:

(1) Holds an active license in the same or a similar specialty as the treating provider;

(2) Is actively practicing in the same or similar field of medicine; and

(3) Has expertise to assess the medical necessity of the specific procedure or service under review.

(b) In any peer-to-peer review conducted by an insurer, the insurer shall disclose to the requesting provider, at or before the start of the peer-to-peer conversation:

(1) The reviewer's full name;

(2) The reviewer's licensure type and issuing state; and

(3) The reviewer's National Provider Identifier (NPI). This disclosure requirement applies regardless of whether the call is initiated by the provider or the insurer.

(c) Failure of the insurer to comply with this section shall constitute an unfair insurance practice under RSA 417 and may be subject to administrative penalties by the insurance commissioner.

3 Utilization Review. Amend RSA 420-J:6, X to read as follows:

X. Option to request a peer-to-peer review. When a health carrier requires prior authorization for an item or service, the carrier shall offer the provider the opportunity to request a peer-to-peer review of a prior authorization request in which the provider is able to have a direct conversational exchange with a medical director or a designated provider who is a clinical peer about the basis for the prior authorization request. A "clinical peer" in this context shall and before a formal grievance request has been madeheath* health carrier shall treat the review request as a request for reconsideration that is external to the grievance process and shall provide the provider and the covered person a written determination containing a statement of the specific reasons for the reconsideration determination with reference to the information provided in the peer-to-peer review. The written reconsideration determination shall be provided within 7 business days of the peer-to-peer review.

4 New Paragraph; Utilization Review; Peer-to-Peer Review Requirements. Amend RSA 420-J:6 by inserting after paragraph X the following new paragraph:

X-a. Upon issuance of an adverse prior authorization determination, an insured or their provider may at any time request and receive a peer-to-peer review, including after an appeal has been initiated. The insurer shall honor such a request regardless of appeal status and schedule the peer-to-peer conversation within 5 business days of the request.

(a) The peer-to-peer review shall be conducted by a physician reviewer who:

(1) Holds an active license in the same or a similar specialty as the treating provider;

(2) Is actively practicing in the same or similar field of medicine; and

(3) Has expertise to assess the medical necessity of the specific procedure or service under review.

(b) In any peer-to-peer review conducted by an insurer, the insurer shall disclose to the requesting provider, at or before the start of the peer-to-peer conversation:

(1) The reviewer's full name;

(2) The reviewer's licensure type and issuing state; and

(3) The reviewer's National Provider Identifier (NPI). This disclosure requirement applies regardless of whether the call is initiated by the provider or the insurer.

(c) Failure of the insurer to comply with this section shall constitute an unfair insurance practice under RSA 417 and may be subject to administrative penalties by the insurance commissioner.

5 Effective Date. This act shall take effect January 1. 2027.