Bill Text: IA SSB1100 | 2023-2024 | 90th General Assembly | Introduced

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Bill Title: A bill for an act relating to prior authorization exemptions for certain health care providers for specific health care services.

Spectrum: Committee Bill

Status: (Introduced) 2023-02-08 - Subcommittee recommends amendment and passage. []. [SSB1100 Detail]

Download: Iowa-2023-SSB1100-Introduced.html

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Senate Study Bill 1100 - Introduced
SENATE FILE _____
BY (PROPOSED COMMITTEE
ON COMMERCE BILL BY
CHAIRPERSON BROWN)
A BILL FOR
An Act relating to prior authorization exemptions for certain
health care providers for specific health care services.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:
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Section 1. NEW SECTION . 514F.9 Prior authorization
exemption —— health care providers.
1. Definitions. For purposes of this section:
a. “Covered person” means the same as defined in section
514F.8.
b. “Evaluation” means either of the following:
(1) A review of the outcomes of preauthorization
requests submitted by a health care provider during the
most recent evaluation period to determine the percentage of
the preauthorization requests that were approved, and that
is conducted to determine whether to grant the health care
provider an exemption for a specific health care service for
which the provider does not have an exemption.
(2) A retrospective review of a random sample of claims
submitted by a health care provider during the most recent
evaluation period to determine the percentage of claims that
would have been approved, based on meeting the health carrier’s
applicable medical necessity criteria at the time the health
care service was provided, and that is conducted to determine
whether to rescind the health care provider’s exemption,
consistent with subsection 5, for a specific health care
service.
c. “Evaluation period” means the six-month period
immediately preceding an evaluation, including all of the
following:
(1) For an initial exemption determination, the evaluation
period shall be the six-month period beginning on January 1,
2024, then each subsequent six-month period beginning on July 1
and ending December 31, and beginning on January 1 and ending
June 30.
(2) After an exemption denial or an exemption rescission
for a specific health care service, the subsequent six-month
evaluation period shall begin on the first day immediately
after the last day of the evaluation period that formed the
basis for the exemption denial or exemption rescission.
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(3) For a retrospective review conducted pursuant to
subsection 5, paragraph “a” , subparagraph (2), the evaluation
period shall be any six-month period selected by the health
carrier.
d. “Exemption” means an exception to a health carrier’s
requirement that a health care provider obtain prior
authorization for a specific health care service.
e. “Facility” means the same as defined in section 514J.102.
f. “Health benefit plan” means the same as defined in
section 514J.102.
g. “Health care professional” means the same as defined in
514J.102.
h. “Health care provider” means the same as defined in
section 514J.102.
i. “Health care services” means the same as defined in
section 514J.102.
j. “Health carrier” means the same as defined in section
514F.108.
k. “Independent review organization” means an entity
that conducts an independent external review of an adverse
determination.
l. “Prior authorization” means the same as defined in
section 514F.8.
m. “Random sample” means between five and twenty claims
for a specific health care service submitted by a health care
provider during the most recent evaluation period.
2. Exemption.
a. A health carrier that requires prior authorization for
certain health care services shall grant a health care provider
an exemption for a specific health care service, if, in the
most recent evaluation period, the health carrier has approved
not less than eighty percent of the health care provider’s
prior authorization requests for the specific health care
service.
b. A health carrier shall conduct an evaluation of each
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health care provider that is contracted with the health carrier
to provide health care services to the health carrier’s covered
persons a minimum of once every six months to determine if the
health care provider qualifies for an exemption under paragraph
“a” . A health carrier may continue a health care provider’s
exemption granted under paragraph “a” without conducting an
evaluation for a specific evaluation period.
c. A health care provider shall not be required to request
an exemption from a health carrier to qualify for an exemption
under paragraph “a” .
d. No later than five calendar days after a health care
provider qualifies for an exemption, the health carrier shall
provide a notice to the health care provider that includes all
of the following:
(1) A statement that the health care provider qualifies for
an exemption under paragraph “a” .
(2) A complete list of all health benefit plans and health
care services to which the exemption applies.
(3) The duration of the exemption.
e. If a health care provider submits a prior authorization
request for a health care service for which the health care
provider qualifies for an exemption under paragraph “a” ,
the health carrier shall promptly provide the notice under
paragraph “d” to the health care provider and an explanation of
the health carrier’s claim submission requirements.
3. Duration of exemption. A health care provider’s
exemption granted under subsection 2, paragraph “a” , shall
remain in effect until either of the following occurs:
a. The health carrier notifies the health care provider
of the health carrier’s decision to rescind the health care
provider’s exemption, and the health care provider fails to
appeal the health carrier’s decision within thirty calendar
days, at which time the health provider’s exemption shall be
rescinded effective thirty-one calendar days after the date of
the health carrier’s rescission notice.
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b. If a health care provider appeals a health carrier’s
decision to rescind the health care provider’s exemption within
the thirty-day appeal period and the decision is upheld on
appeal, the health provider’s exemption shall be rescinded
effective five calendar days after the date the rescission
decision is upheld.
4. Denial of exemption. A health carrier may deny an
exemption for a health care provider for a specific health
care service if the health carrier provides the health care
provider with sufficient statistics and documentation for the
relevant evaluation period to demonstrate that the health
care provider does not meet the health carrier’s criteria for
exemption. The health carrier shall notify the health care
provider not more than five calendar days after the date of the
health carrier’s decision to deny the exemption. At the same
time as the notice, the health carrier must provide the health
care provider with a plain-language explanation of the health
care provider’s right to an appeal of, or to an independent
review of, the health carrier’s decision, and of the process
for the health care provider to file an appeal or to request an
independent review.
5. Rescission of exemption.
a. A health carrier may rescind a health care provider’s
exemption for a specific health care service granted under
subsection 2, paragraph “a” , at any of the following times:
(1) During January or June of each calendar year.
(2) If, during a retrospective review of a random sample
of the health care provider’s claims, the health carrier
determines that less than eighty percent of the claims for
the specific health care service met the medical necessity
and appropriateness criteria used by the health carrier for
conducting a prior authorization review for the specific
health care service during the relevant evaluation period. A
determination made under this subsection must be made by a
health care professional licensed to practice medicine in this
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state. If a determination is made with respect to a health
care professional who is a physician, the determination must
be made by a physician licensed in this state who has either
the same or a similar medical specialty as the health care
professional.
b. The health carrier must notify the health care provider
not less than thirty calendar days before the date that the
rescission is effective. At the same time as the notice, the
health carrier must provide the health care provider with all
of the following:
(1) Sufficient statistics and documentation from the
health carrier’s retrospective review under paragraph “a” ,
subparagraph (2), to substantiate the health carrier’s decision
to rescind the health care provider’s exemption.
(2) A plain-language explanation of the health care
provider’s right to an appeal of, or to an independent review
of, the health carrier’s decision to rescind the health care
provider’s exemption, and of the process for the health care
provider to file an appeal or to request an independent review.
6. Appeal or independent review.
a. A health care provider shall have the right to appeal an
adverse exemption determination, and have the right to a review
of the determination by an independent review organization.
A health carrier shall not require a health care provider to
participate in the health carrier’s internal appeal process
prior to requesting an independent review.
b. The health carrier shall pay the cost of an appeal
and the cost of an independent review requested by a health
care provider under this subsection. The costs shall include
reasonable fees for copies of applicable medical records or
other documents requested from the health care provider during
the internal appeal or the independent review.
c. (1) An independent review organization shall complete an
independent review requested by a health care provider under
this section no later than thirty calendar days after the date
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of the health care provider’s request.
(2) A health care provider may request that the independent
review organization evaluate an additional random sample from
the relevant evaluation period as part of the independent
review organization’s review. If the health care provider
requests that the independent review organization evaluate an
additional random sample, the independent review organization
shall base its determination on the medical necessity and
appropriateness of both the random samples reviewed under
subsection 5, paragraph “a” , subparagraph (2), and the random
samples reviewed under this subparagraph.
d. The health carrier and the health care provider shall
be bound by the appeal decision or by the independent review
organization’s determination.
e. If a health carrier’s adverse exemption determination is
overturned on appeal or by an independent review organization,
the health carrier shall not attempt to rescind the health care
provider’s exemption prior to the end of the next-occurring
evaluation period. After the date on which the next-occurring
evaluation period ends, the health carrier may rescind the
health care provider’s exemption if the health carrier complies
with subsection 5 and this subsection.
f. A health carrier shall not retroactively deny a health
care service for a covered person on the basis of the health
carrier’s rescission of the health care provider’s exemption,
even if the health carrier’s rescission decision is affirmed on
appeal or by an independent review organization.
7. Exemption eligibility after rescission or denial. If
an appeal or an independent review organization affirms a
rescission or a denial of a health care provider’s exemption
for a specific health care service, the health care provider
shall be eligible for an exemption for the same health care
service after the last day of the six-month evaluation period
immediately following the evaluation period that was the basis
for the denial or rescission.
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8. Effect of exemption.
a. A health carrier shall not deny or reduce payment on a
health care provider’s claim based on the medical necessity or
medical appropriateness of care for a health care service for
which the health care provider qualified for an exemption under
subsection 2, unless the health care provider knowingly and
materially misrepresented the health care service in the claim
with the specific intent to deceive the health carrier and to
obtain an unlawful claim payment.
b. A health carrier shall not conduct a retrospective review
of a health care service provided by a health care provider who
has been allowed an exemption for the health care service under
subsection 2, except in the following circumstances:
(1) Pursuant to subsection 5, paragraph “a” , subparagraph
(2).
(2) The health carrier has reasonable cause to suspect a
basis for denial of a claim under paragraph “a” .
9. Scope of practice. This section shall not be construed
to permit a health care provider to provide a health care
service outside the scope of the health care provider’s
license, or to require a health carrier to pay a claim
submitted by a health care provider for a health care service
outside the scope of the health care provider’s license.
10. Applicability. This section applies to all health
benefit plans delivered, issued for delivery, continued, or
renewed in this state on or after January 1, 2024.
EXPLANATION
The inclusion of this explanation does not constitute agreement with
the explanation’s substance by the members of the general assembly.
This bill relates to prior authorization exemptions for
certain health care providers for certain health care services.
The bill requires health carriers (carrier) that require
prior authorization for certain health care services (services)
to grant a health care provider (provider) an exemption,
if, in the most recent evaluation period (period), the
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carrier has approved not less than 80 percent of the prior
authorization requests submitted by that provider for the
specific service. “Exemption” is defined in the bill as an
exception to a carrier’s requirement that a provider obtain
prior authorization for a specific service. “Evaluation
period” is defined in the bill.
A carrier shall conduct an evaluation of each health
provider that is contracted with the carrier to provide
services to the carrier’s covered persons a minimum of once
every six months to determine if the provider qualifies for an
exemption. “Evaluation” is defined in the bill. A carrier
may continue an exemption without conducting an evaluation for
a specific evaluation period. A provider is not required to
request a provider’s exemption from a carrier to qualify for an
exemption. No later than five calendar days after a provider
qualifies for an exemption, the carrier shall provide a notice
to the provider that includes a statement that the provider
qualifies for an exemption, a complete list of all health
benefit plans and services to which the exemption applies, and
the duration of the exemption. If a provider submits a prior
authorization request for a service for which the provider
qualifies for an exemption, the carrier shall promptly provide
the provider with the same notice.
If a carrier notifies a provider of the carrier’s decision
to rescind the provider’s exemption and the provider fails to
appeal the decision within 30 calendar days, the provider’s
exemption is rescinded effective 31 calendar days after the
date of the carrier’s notice. If the provider appeals the
carrier’s decision within the 30-day appeal period and the
decision is upheld on appeal, the provider’s exemption shall
be rescinded five calendar days after the date the decision is
upheld.
A carrier may deny an exemption for a provider for a
specific service if the carrier provides the provider with
sufficient statistics and documentation for the relevant
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period to demonstrate that the provider does not meet the
carrier’s criteria for exemption. The carrier must satisfy the
notification requirements detailed in the bill.
A carrier may rescind a provider’s exemption during January
or June of each year, or if a retrospective review of a
random sample of the provider’s claims show that less than 80
percent of the claims for the specific service met the medical
necessity and appropriateness criteria used by the carrier
for conducting a prior authorization review for the specific
service during the relevant period. “Random sample” is defined
in the bill. The determination must be made by a health care
professional licensed to practice medicine in this state, and
if the determination is made with respect to a health care
professional who is a physician, the determination must be made
by a physician licensed in this state who has either the same
or a similar medical specialty as the health care professional.
The carrier must notify the provider not less than 30 days
before the date the rescission is effective. The carrier must
provide the provider with documentation, as detailed in the
bill, with the notice.
A provider shall have the right to appeal an adverse
exemption determination as detailed in the bill, and the
carrier and provider are bound by the appeal decision or the
independent review organization’s (organization) determination.
If a carrier’s adverse exemption determination is overturned
by an organization, the carrier shall not attempt to rescind
the provider’s exemption prior to the end of the next occurring
period. A carrier shall not retroactively deny a service
on the basis of the carrier’s rescission of the provider’s
exemption, even if the carrier’s decision is affirmed on appeal
or by an organization’s determination. If an appeal or an
organization’s determination affirms the rescission or denial
of a provider’s exemption for a specific service, the provider
shall be eligible for an exemption for the same service after
the last day of the six-month period immediately following the
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period that was the basis for the denial or rescission.
A carrier shall not deny or reduce payment on a provider’s
claim based on the medical necessity or appropriateness
of care for a service for which the provider qualified for
an exemption, unless the provider knowingly and materially
misrepresented the service in the claim with the specific
intent to deceive the carrier and to obtain an unlawful
claim payment on the claim. A carrier shall not conduct a
retrospective review of a service provided by a provider who
has been granted an exemption for the service except in the
circumstances detailed in the bill.
The bill shall not be construed to permit a provider to
provide a service outside the scope of the provider’s license,
or to require a carrier to pay a claim submitted by a provider
for a service outside the scope of the provider’s license.
The bill applies to all health benefit plans delivered,
issued for delivery, continued, or renewed in this state on or
after January 1, 2024.
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