(a)A healthcare insurer shall not deny or reduce payment to a healthcare provider for a healthcare service for which the healthcare provider has qualified for an exemption from prior authorization requirements under § 23-99-1120 , including a healthcare service performed or supervised by another healthcare provider, if the healthcare provider who ordered the healthcare service received a prior authorization exemption based on medical necessity or appropriateness of care unless the healthcare provider:
(1)Knowingly and materially misrepresented the healthcare service in a request for payment submitted to the healthcare insurer with the specific intent to deceive the healthcare insurer and obtain an unlawful payment from the healthcare insurer; or (2) Substantially failed to perform the he
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(a) A healthcare insurer shall not deny or reduce payment to a healthcare provider for a healthcare service for which the healthcare provider has qualified for an exemption from prior authorization requirements under § 23-99-1120 , including a healthcare service performed or supervised by another healthcare provider, if the healthcare provider who ordered the healthcare service received a prior authorization exemption based on medical necessity or appropriateness of care unless the healthcare provider: (1) Knowingly and materially misrepresented the healthcare service in a request for payment submitted to the healthcare insurer with the specific intent to deceive the healthcare insurer and obtain an unlawful payment from the healthcare insurer; or (2) Substantially failed to perform the healthcare service. (b) A healthcare insurer shall not conduct a retrospective review of a healthcare service subject to an exemption except: (1) To determine if the healthcare provider still qualifies for an exemption under § 23-99-1120 ; or (2) If the healthcare insurer has a reasonable cause to suspect a basis for denial exists under subsection (a) of this section. (c) For a retrospective review described by subdivision (b)(2) of this section, §§ 23-99-1120 - 23-99-1125 shall not modify or otherwise affect: (1) The requirements under or application of § 23-99-1115 , including without limitation any time frames; or (2) Any other applicable law, except to prescribe the only circumstances under which: (A) A retrospective review may occur as specified by subdivision (b)(2) of this section; or (B) Payment may be denied or reduced as specified by subsection (a) of this section. (d) Beginning on January 1, 2024, a healthcare insurer shall provide to a healthcare provider a notice that includes a: (1) Statement that the healthcare provider has an exemption from prior authorization requirements under § 23-99-1120 ; (2) List of the healthcare services and health benefit plans to which the exemption applies; and (3) Statement of the duration of the exemption. (e) If a healthcare provider submits a prior authorization request for a healthcare service for which the healthcare provider has an exemption from prior authorization requirements under § 23-99-1120 , the healthcare insurer shall promptly provide a notice to the healthcare provider that includes: (1) The information described in subsection (d) of this section; and (2) A notification of the healthcare insurer's payment requirements. (f) This section and §§ 23-99-1120 - 23-99-1125 shall not be construed to: (1) Authorize a healthcare provider to provide a healthcare service outside the scope of the healthcare provider's applicable license; or (2) Require a healthcare insurer to pay for a healthcare service described by subdivision (f)(1) of this section that is performed in violation of the laws of this state. (g) A healthcare insurer that offers multiple health benefit plans or that utilizes multiple healthcare provider networks shall not determine a healthcare provider's eligibility for an exemption from prior authorization for each specific health benefit plan or each specific healthcare provider network but rather shall determine the healthcare provider's eligibility for an exemption applicable to all health benefit plans and healthcare provider networks. (h) If a healthcare insurer and a healthcare provider are engaged in a value-based reimbursement arrangement for particular healthcare services or subscribers, the healthcare insurer shall not impose any prior authorization requirements for any particular healthcare service that is included in that value-based reimbursement arrangement.