§ 23-99-1301. Definitions
As used in this subchapter: (1) “Contracting entity” means a healthcare insurer or any subcontractor, affiliate, or other entity that contracts directly or indirectly with a healthcare provider for the delivery of healthcare services to enrollees; (2) “Enrollee” means a person who is entitled to receive healthcare services under the terms of a health benefit […]
§ 23-99-1302. Assignment of benefits
(a) An enrollee, through an assignment of benefits, may assign to a healthcare provider the enrollee’s right to receive reimbursement for any healthcare service rendered by a healthcare provider regardless of whether the healthcare provider is a participating provider or an out-of-network provider. (b) (1) A healthcare provider that is provided an assignment of benefits […]
§ 23-99-1303. Waiver prohibited
(a) This subchapter shall not be waived by contract. (b) A contractual arrangement or actions taken in conflict with this subchapter or that purport to waive any requirement of this subchapter are void.
§ 23-99-1304. Enforcement
(a) A contracting entity is subject to the Trade Practices Act, § 23-66-201 et seq. (b) The State Insurance Department shall enforce this subchapter.
§ 23-99-1117. Standardized form required for prescription drug benefits
(a) On and after January 1, 2017, to establish uniformity in the submission of prior authorization forms for prescription drugs, a utilization review entity shall utilize only a single standardized prior authorization form for obtaining approval in written or electronic form for prescription drug benefits. (b) A utilization review entity may make the form required […]
§ 23-99-1305. Rules
(a) The Insurance Commissioner shall promulgate rules necessary to ensure compliance with this subchapter. (b) (1) When adopting the initial rules to ensure compliance with this subchapter, the final rule shall be filed with the Secretary of State for adoption under § 25-15-204(f): (A) On or before March 1, 2020; or (B) If approval under […]
§ 23-99-1118. Rules
The State Insurance Department may promulgate rules for the implementation of this subchapter.
§ 23-99-1103. Definitions
As used in this subchapter: (1) (A) “Adverse determination” means a decision by a utilization review entity to deny, reduce, or terminate coverage for a healthcare service furnished or proposed to be furnished to a subscriber on the basis that the healthcare service is not medically necessary or is experimental or investigational in nature. (B) […]
§ 23-99-1104. Disclosure required
(a) (1) A utilization review entity shall disclose all of its prior authorization requirements and restrictions, including any written clinical criteria, in a publicly accessible manner on its website. (2) The information described in subdivision (a)(1) of this section shall be explained in detail and in clear and ordinary terms. (3) (A) Utilization review entities […]
§ 23-99-1105. Prior authorization — Nonurgent healthcare service
(a) If a utilization review entity requires prior authorization of a nonurgent healthcare service, the utilization review entity shall make an authorization or adverse determination and notify the subscriber and the subscriber’s nonurgent healthcare provider of the decision within two (2) business days of obtaining all necessary information to make the authorization or adverse determination. […]