(a)(1) Except as provided under subdivision (a)(2) of this section, beginning on and after January 1, 2024, a healthcare provider that received approval for ninety percent (90%) or more of the healthcare provider's prior authorization requests based on a review of the healthcare provider's utilization of the particular healthcare services from January 1, 2022, through June 30, 2022, shall not be required to obtain prior authorization for a particular healthcare service and shall be considered exempt from prior authorization requirements through September 30, 2024.
(2)If a healthcare provider's use for a particular healthcare service increases by twenty-five percent (25%) or more during the period between January 1, 2024, and June 30, 2024, based on a review of the healthcare provider's u
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(a) (1) Except as provided under subdivision (a)(2) of this section, beginning on and after January 1, 2024, a healthcare provider that received approval for ninety percent (90%) or more of the healthcare provider's prior authorization requests based on a review of the healthcare provider's utilization of the particular healthcare services from January 1, 2022, through June 30, 2022, shall not be required to obtain prior authorization for a particular healthcare service and shall be considered exempt from prior authorization requirements through September 30, 2024. (2) If a healthcare provider's use for a particular healthcare service increases by twenty-five percent (25%) or more during the period between January 1, 2024, and June 30, 2024, based on a review of the healthcare provider's utilization of the particular healthcare service from January 1, 2022, through June 30, 2022, then the healthcare insurer may disallow the exemption from prior authorization requirements for the healthcare provider for the particular healthcare service. (b) (1) A healthcare insurer shall conduct an evaluation of the initial six-month exemption period based on claims submitted between January 1, 2024, through June 30, 2024, to determine whether to grant or deny an exemption for each particular healthcare service that requires a prior authorization by the healthcare insurer. (2) The evaluation by the healthcare insurer shall be conducted by using the retrospective review process under § 23-99-1122(c) and applying the criteria under subsection (d) of this section. (3) A healthcare insurer shall submit to a healthcare provider a written statement of: (A) The total number of payable claims submitted by or in connection with the healthcare provider; and (B) The total number of denied and approved prior authorizations between January 1, 2022, through June 30, 2022. (c) (1) No later than October 1, 2024, a healthcare insurer shall issue a notice to each healthcare provider that either grants or denies a prior authorization exemption to the healthcare provider for each particular healthcare service. (2) An exemption granted under this subdivision (c)(1) shall be valid for at least twelve (12) months. (d) Except as provided under subsection (f) of this section or § 23-99-1125 , a healthcare insurer that uses a prior authorization process for healthcare services shall not require a healthcare provider to obtain prior authorization for a particular healthcare service that a healthcare provider has previously been subject to a prior authorization requirement if, in the most recent six-month evaluation period as described under subsection (e) of this section, the healthcare insurer has approved or would have approved no less than ninety percent (90%) of the prior authorization requests submitted by the healthcare provider for that particular healthcare service. (e) (1) Except as provided under subsection (f) of this section, a healthcare insurer shall evaluate whether or not a healthcare provider qualifies for an exemption from prior authorization requirements under subsection (d) of this section one (1) time every twelve (12) months. (2) The six-month period for the evaluation period described under subsection (d) of this section shall be any consecutive six-month period during the twelve (12) months following the effective date of the exemption. (3) The healthcare insurer shall choose a six-month evaluation period that allows time for: (A) The evaluation under subsection (d) of this section; (B) Notice to the healthcare provider of the decision; and (C) Appeal of the decision for an independent review to be completed by the end of the twelve-month period of the exemption. (f) A healthcare insurer may continue an exemption under subsection (d) of this section without evaluating whether or not the healthcare provider qualifies for the exemption under subsection (d) of this section for a particular evaluation period. (g) A healthcare provider is not required to request an exemption under subsection (d) of this section to quality for the exemption. (h) A healthcare insurer may extend an exemption under subsection (d) of this section to a group of healthcare providers under the same tax identification number if: (1) A healthcare provider with an ownership interest in the entity to which the tax identification number is assigned does not object; or (2) The tax identification number is associated with a hospital licensed in this state and the chief executive officer of the hospital agrees to the exemption.