§ 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) […]
§ 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. […]
§ 23-99-1106. Prior authorization — Urgent healthcare service
A utilization review entity shall render an expedited authorization or adverse determination concerning an urgent healthcare service and notify the subscriber and the subscriber’s healthcare provider of that expedited prior authorization or adverse determination no later than one (1) business day after receiving all information needed to complete the review of the requested urgent healthcare […]
§ 23-99-1107. Prior authorization — Emergency healthcare service
(a) A utilization review entity shall not require prior authorization for prehospital transportation or for provision of an emergency healthcare service. (b) (1) A utilization review entity shall allow a subscriber and the subscriber’s healthcare provider a minimum of twenty-four (24) hours following an emergency admission or provision of an emergency healthcare service for the […]
§ 23-99-1108. Subscribers with terminal illness — Denial of prior authorization for covered prescription pain medication prohibited
If a subscriber’s covered prescription pain medication requires a prior authorization, then the prior authorization shall not be denied if the subscriber has a terminal illness.
§ 23-99-1109. Rescission of prior authorizations — Denial of payment for prior authorized services — Limitations
(a) A decision on a request for prior authorization by a utilization review entity shall include a determination as to whether or not the individual is covered by a health benefit plan and eligible to receive the requested service under the health benefit plan. (b) (1) A utilization review entity shall not rescind, limit, condition, […]
§ 23-99-1110. Waiver prohibited
(a) The provisions of this subchapter shall not be waived by contract. (b) Any contractual arrangements or actions taken in conflict with this subchapter or that purport to waive any requirements of this subchapter are void.
§ 23-99-1111. Requests for prior authorization — Qualified persons authorized to review and approve — Adverse determinations to be made only by Arkansas-licensed physicians
(a) The initial review of information submitted in support of a request for prior authorization may be conducted by a qualified person employed or contracted by a utilization review entity. (b) A request for prior authorization may be approved by a qualified person employed or contracted by a utilization review entity. (c) (1) An adverse […]
§ 23-99-1112. Application of subchapter
This subchapter applies to a healthcare insurer, whether or not the healthcare insurer is acting directly or indirectly through a private utilization review entity.
§ 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 […]
§ 23-99-1114. 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 […]
§ 23-99-1115. 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 […]
§ 23-99-1116. 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.
§ 23-99-1117. 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 […]
§ 23-99-1118. Rules
The State Insurance Department may promulgate rules for the implementation of this subchapter.
§ 23-99-1119. Medication-assisted treatment for opioid addiction
(a) Except in the case of injectables, a healthcare insurer, including Medicaid, shall not: (1) Require prior authorization in order for a patient to obtain coverage of buprenorphine, naloxone, naltrexone, methadone, and their various formulations and combinations approved by the United States Food and Drug Administration for the treatment of opioid addiction; or (2) Impose […]