§ 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. (b) For purposes of this section, "necessary information" includes the results of any face-to-face clinical evaluation or second opinion that may be required. (c) (1) If a utilization review entity denies a prior authorization of a nonurgent healthcare service, then the subscriber or the healthcare provider may elect to appeal the denial of the prior authorization of the nonurgent healthcare service. (2) If a denial of a prior authorization of a nonurgent healthcare service is appealed to the utilization review entity, then within four (4) business days of receiving all necessary information required, the utilization review entity shall: (A) Make an authorization or adverse determination; and (B) Notify the subscriber and the healthcare provider that appealed the denial of the prior authorization of the nonurgent healthcare service of the decision. (3) This subsection applies to an enrollee who is being evaluated or treated for: (A) A hematology diagnosis; (B) An oncology diagnosis; or (C) An additional disease state or other diagnoses that the Insurance Commissioner may include by rule.

Legislative History

Amended by Act 2023, No. 501,§ 2, eff. 8/1/2023. Added by Act 2015, No. 1106,§ 2, eff. 7/22/2015.