§ 23-99-1113. Benefit inquiries authorized
(a) (1) An in-network or out-of-network healthcare provider may submit a benefit inquiry to a healthcare insurer or utilization review entity for a healthcare service not yet provided to determine whether or not the healthcare service meets medical necessity and all other requirements for payment under a health benefit plan if the healthcare service were […]
§ 23-99-1003. Prohibited practices — Agreements
(a) A participating provider agreement between an insurer, vision care plan, or vision care discount plan and a vision care provider shall not establish a fee that a vision care provider shall charge for services or materials that are not covered by a vision benefit plan or contract. (b) A vision care provider shall not […]
§ 23-99-1114. Limitations on step therapy — Definition
(a) If a utilization review entity has required a healthcare provider to utilize step therapy for a specific prescription drug for a subscriber, the utilization review entity shall not require the healthcare provider to utilize step therapy a second time for that same prescription drug, even though the utilization review entity or healthcare insurer may […]
§ 23-99-1004. Private civil action
(a) A vision care provider adversely affected by any violation of this subchapter by an insurer, vision care plan, or a vision care discount plan may bring a civil action in a court of competent jurisdiction against the insurer, vision care plan, or a vision care discount plan for injunctive relief. (b) If a person […]
§ 23-99-1115. Notice requirements — Process for appealing adverse determination and restriction or denial of healthcare service
(a) (1) Notice of an adverse determination shall be provided to the healthcare provider that initiated the prior authorization. (2) Notice may be made by electronic mail, fax, or hard copy letter sent by regular mail, or verbally, as requested by the subscriber’s healthcare provider. (b) The written or verbal notice required under this section […]
§ 23-99-1005. Rules — Enforcement — Effective date
(a) The State Insurance Department shall develop and promulgate rules for the implementation and administration of this subchapter. (b) The Insurance Commissioner shall enforce this subchapter and may seek injunctive relief for violations of this subchapter. (c) This subchapter is applicable to a vision benefit plan or contract issued, renewed, or recredentialed in this state […]
§ 23-99-1116. Failure to comply with subchapter — Requested healthcare services deemed approved
(a) If a healthcare insurer or utilization review entity fails to comply with this subchapter, the requested healthcare services shall be deemed authorized or approved. (b) A healthcare service that is authorized or approved under this section is not subject to audit recoupment under § 23-63-1801 et seq.
§ 23-99-1101. Title
This subchapter shall be known and may be cited as the “Prior Authorization Transparency Act”.
§ 23-99-1102. Legislative findings and intent
(a) The General Assembly finds that: (1) A physician-patient relationship is paramount and should not be subject to third-party intrusion; and (2) Prior authorizations can place attempted cost savings ahead of optimal patient care. (b) The General Assembly intends for this subchapter to: (1) Ensure that prior authorizations do not hinder patient care or intrude […]
§ 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) […]