§ 20-3401 – Definitions
20-3401. Definitions In this article, unless the context otherwise requires: 1. " Adverse determination" : (a) Means a decision by a health care services plan or its utilization review agent that the health care services furnished or proposed to be furnished to an enrollee are not medically necessary and plan coverage is therefore denied, reduced […]
§ 20-3402 – Prior authorization; exceptions
20-3402. Prior authorization; exceptions A. A health care services plan or its utilization review agent may impose a prior authorization requirement for health care services provided to an enrollee, except for emergency ambulance services and emergency services as specified in section 20-2803, health care services arising after the initial medical screening examination and immediately necessary […]
§ 20-3403 – Prior authorization requirements; disclosures; access
20-3403. Prior authorization requirements; disclosures; access A. If a health care services plan contains a prior authorization requirement, all of the following apply: 1. The health care services plan or its utilization review agent shall make available to all providers on its website or provider portal a listing of all prior authorization requirements. The listing […]
§ 20-3404 – Prior authorization requirement timelines
20-3404. Prior authorization requirement timelines A. If a plan offered by a health care services plan contains a prior authorization requirement, all of the following apply: 1. For prior authorization requests concerning urgent health care services, the health care services plan or its utilization review agent shall notify the provider of the prior authorization or […]
§ 20-3405 – Prior authorization of prescription drugs for chronic pain conditions
20-3405. Prior authorization of prescription drugs for chronic pain conditions A. For a prior authorization request related to a chronic pain condition, the health care services plan or its utilization review agent shall honor a prior authorization that is granted for an approved prescription drug for the earliest of the following: 1. Six months after […]
§ 20-3406 – Uniform prior authorization request forms; definition
20-3406. Uniform prior authorization request forms; definition A. Notwithstanding any other law, on or before January 1, 2022, the department shall approve a uniform prior authorization request form for prescription drugs, devices or durable medical equipment and a uniform prior authorization request form for all other health care procedures, treatments and services. On or before […]