Patients and Medical Providers Cheer “Prior Authorization” Reform

July 25, 2016Articles

Rules surrounding prior authorization (PA) for coverage of some prescriptions and medical procedures have frustrated both doctors and patients. SB 129 aims to reduce some of those frustrations. Beginning next year, four reforms take place. They are:

1. Insurer Disclosure

Insurers must disclose all PA rules to participating providers complete with a list of what a provider must submit in order to be deemed “complete.” Insurers must give 30 days advance notice to providers of new PA requirements. Health plan enrollees must receive basic information as to what procedures require PA.

2. Retroactive Denials Barred

Insurers cannot revoke a prior grant of PA if, at the time the provider rendered the service, the patient is enrolled in the plan, his condition has not changed, and the provider’s claim matches the information the provider submitted in order to gain the prior approval.

3. PA is “Good” For 12 Months For Chronic Disease Medications

Insurers must allow a PA to be valid for 12 months for medications to treat chronic diseases (with certain exceptions).

4. After-The-Fact PA to be Granted Under Certain Circumstances

Where a PA for a service was required but not obtained, coverage is still required where, based on a retrospective review, it is determined the service in question relates to another service performed for which PA was obtained; the new service was not known to be needed when the PA for the originally approved service was given; and when the need for the new service was revealed when the original service was performed.

Starting in 2018, further reforms will become effective. They are:

1. Electronic PA Requests and Approvals

Insurers must maintain a web-based electronic system to receive and respond to PA requests.

2. Expedited PA Process

Insurers must approve or deny PA requests in “urgent situations” within 48 hours and in all other cases within 10 calendar days. Insurers must give a specific reason for each denial and specifically list what additional information is needed if a PA request is incomplete.

3. Expedited Appeals

Appeals must be considered within 48 hours (urgent situations) or 10 calendar days after receipt of the appeal. If internal appeals between the medical provider and the insurer’s in-house clinical peer do not resolve the matter, the patient may seek an external appeal to be decided by a neutral, independent medical expert.

NOTE: This bill applies to all health insurers operating in Ohio, including Medicaid managed care plans, but DOES NOT apply to ERISA self-insured plans or Medicare Advantage plans over which the federal government has exclusive jurisdiction.