§ 23-99-1104 — Disclosure required

(a) (1) (A) A utilization review entity shall disclose all of its prior authorization requirements and restrictions in a publicly accessible manner on its website. (B) The disclosure under subdivision (a)(1)(A) of this section shall include: (i) A list of any healthcare services that require prior authorization; and (ii) Any written clinical criteria. (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 that have agreed, by contract with vendors or third-party administrators, to use licensed, proprietary, or copyrighted protected clinical criteria from the vendors or administrators may satisfy the disclosure requirement under subdivision (a)(1) of this section by making all relevant proprietary clinical criteria available to a healthcare provider that submits a prior authorization request to the utilization review entity through a secured link on the utilization review entity's website that is accessible to the healthcare provider from the public part of its website as long as any link or access restrictions to the information do not cause any delay to the healthcare provider. (B) For out-of-network providers, a utilization review entity may meet the requirements of this subdivision (a)(3) by: (i) Providing the healthcare provider with temporary electronic access in a timely manner to a secure site to review copyright-protected clinical criteria; or (ii) Disclosing copyright-protected clinical criteria in a timely manner to a healthcare provider through other electronic or telephonic means. (b) Before a utilization review entity implements a new or amended prior authorization requirement or restriction as described in subdivision (a)(1) of this section, the utilization review entity shall update its website to reflect the new or amended requirement or restriction. (c) Before implementing a new or amended prior authorization requirement or restriction, a utilization review entity shall provide contracted healthcare providers written notice of the new or amended requirement or restriction at least sixty (60) days before implementation of the new or amended requirement or restriction. (d) (1) A utilization review entity shall make statistics available regarding prior authorization approvals and denials on its website in a readily accessible format. (2) The statistics made available by a utilization review entity under this subsection shall categorize approvals and denials by: (A) Physician specialty; (B) Medication or diagnostic test or procedure; (C) Medical indication offered as justification for the prior authorization request; and (D) Reason for denial.

Legislative History

Amended by Act 2023, No. 575,§ 3, eff. 8/1/2023. Amended by Act 2017, No. 815,§ 3, eff. 8/1/2017. Added by Act 2015, No. 1106,§ 2, eff. 7/22/2015.