We are planning an upcoming virtual event to share best practices on prior authorizations. We are hoping to host this in June and will be sharing additional details shortly. We will make sure that all clinical champions at the practices receive an invitation to attend this.
Prior authorization procedures vary between practices based on a number of factors including office staffing. Senate Bill 247 was signed into law on April 7th, 2022, and reforms the prior authorization process to do the following: 1.) Require an insurer to make available, by June 1, 2023, a standardized electronic prior authorization request transaction process.
2.) Require prior authorization requirements to be based on peer-reviewed clinical review criteria.
3.) Require an insurer to post on its website if it implemented a new prior authorization requirement or restriction or amended an existing requirement or restriction.
4.) Require an insurer to notify, on issuing a medical benefit denial, the health professional and insured or enrollee of certain information, including the right to appeal the adverse determination, and require an appeal of the denial to be reviewed by a health professional.
5.) For a medical benefit that is not a prescription drug benefit, an insurer shall notify contracted health care providers via the insurer's provider portal of the new or amended requirement or restriction not less than 60 days before the requirement or restriction is implemented.
6) For a prescription drug benefit, an insurer shall notify contracted health care providers via the insurer's provider portal of the new or amended requirement or restriction not less than 45 days before the requirement or restriction is implemented.
7) Prohibits an insurer or its designee utilization review organization from affirming the denial of an appeal unless the appeal was reviewed by a licensed physician.
8) For urgent requests, beginning June 1, 2023, the prior authorization is considered granted if the insurer fails to act within 72 hours of the original submission. For non-urgent requests, beginning June 1, 2023, the prior authorization is considered granted if the insurer fails to act within 9 calendar days of the original submission. After May 31, 2024, a non-urgent prior authorization is considered granted if the insurer fails to act within 7 calendar days of the original submission.
9) Requires an insurer to adopt a program that promotes the modification of prior authorization requirements of certain prescription drugs, medical care, or related benefits, based on the performance of the health care providers with respect to adherence to nationally recognized evidence-based medical guidelines and other quality criteria (i.e., BCBSM “gold carding” program).