§ 23-99-1111 — Requests for prior authorization - Qualified persons authorized to review and approve - Adverse determinations to be made only by Arkansas-licensed physicians - Opportunity to discuss treatment before adverse determination

(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 determination regarding a request for prior authorization shall be made by a physician who possesses a current and unrestricted license to practice medicine in the State of Arkansas issued by the Arkansas State Medical Board. (2) (A) A utilization review entity shall provide a method by which a physician may request that a prior authorization request be reviewed by a physician in the same specialty as the physician making the request, by a physician in another appropriate specialty, or by a pharmacologist. (B) If a request is made under subdivision (c)(2)(A) of this section, the reviewing physician or pharmacologist is not required to meet the requirements of subdivision (c)(1) of this section. (3) (A) Subject to this subdivision (c)(3), when an adverse determination is issued by a utilization review entity that questions the medical necessity, the appropriateness, or the experimental or investigational nature of a healthcare service, the utilization review entity shall provide in the notice of adverse determination the name and telephone number of a physician who possesses a current and unrestricted license in this state with whom the requesting healthcare provider may have a reasonable opportunity to discuss the patient's treatment plan and the clinical basis for the intervention. (B) The requesting healthcare provider may contact the reviewing physician at the telephone number provided with the adverse determination under subdivision (c)(3)(A) of this section within one (1) business day of receipt of the adverse determination for an urgent service, or within two (2) business days of receipt of the adverse determination for a nonurgent service, to engage in the discussion of the patient's treatment plan and the clinical basis for the intervention under subdivision (c)(3)(A) of this section. (C) (i) Following any discussion under subdivision (c)(3)(B) of this section, the utilization review entity shall notify the healthcare provider whether or not the adverse determination decision remains the same or the service is approved. (ii) The notice under subdivision (c)(3)(C)(i) of this section shall be provided: (a) Within one (1) business day of the discussion under subdivision (c)(3)(B) of this section between the provider and physician for an urgent service; or (b) Within two (2) business days of the discussion under subdivision (c)(3)(B) of this section between the provider and physician for a nonurgent service. (D) A discussion under subdivision (c)(3)(A) of this section shall not replace or eliminate the opportunity for any internal grievance or appeal process provided by the utilization review entity. (E) If a requesting healthcare provider is a physician, then the reviewing physician with whom the requesting physician is given an opportunity to discuss the treatment plan and clinical basis for the intervention under subdivision (c)(3)(B) of this section shall be a physician who: (i) Possesses a current and unrestricted license to practice medicine in this state; and (ii) Has the same or similar specialty as the healthcare provider.

Legislative History

Amended by Act 2023, No. 575,§ 4, eff. 8/1/2023. Amended by Act 2017, No. 815,§ 8, eff. 8/1/2017. Added by Act 2015, No. 1106,§ 2, eff. 7/22/2015.