§ 26-55-112 — Provider exemptions from prior authorization requirements. Note: this section is effective as of 1/1/2026

(a) A health care provider, as identified by a unique
national provider identifier, shall be granted a twelve (12)
month or one (1) year exemption from completing a prior
authorization request for a health care service, excluding the
practice of pharmacy and prescription drugs, if:
(i) In the most recent twelve (12) month period, the
health insurer or contracted utilization review entity has
authorized not less than ninety percent (90%) of the prior
authorization requests, rounded down to the nearest whole
number, submitted by the health care provider for that health
care service; and
(ii) The health care provider has made a prior
authorization request for that health care service not less than
five (5) times in the most recent twelve (12) month period.
(b) A health insurer or contracted utilization review
entity may evaluate whether a health care provider continues to
qualify for exemptions as described in subsection (a) of this
section. Nothing in this section shall require a health insurer
or contracted utilization review entity to evaluate an existing
exemption under subsection (a) of this section or prevent a
health insurer or contracted utilization review entity from
establishing a longer exemption period.
(c) A health care provider is not required to request an
exemption in order to receive an exemption under subsection (a)
of this section.
(d) A health care provider who does not receive an
exemption under subsection (a) of this section may request from
the health insurer or contracted utilization review entity up to
one (1) time per calendar year per service, evidence to support
the health insurer or contracted utilization review entity's
decision. A health care provider may appeal a health insurer or
contracted utilization review entity's decision to deny an
exemption.
(e) A health insurer or contracted utilization review
entity shall only revoke an exemption at the end of a twelve
(12) month period if the health insurer or contracted
utilization review entity:
(i) Makes a determination that the health care
provider would not have met the ninety percent (90%), rounded
down to the nearest whole number, authorization criteria based
on a retrospective review of the claims for the particular
service for which the exemption applies;
(ii) Provides the health care provider with the
information it relied upon in making its determination to revoke
the exemption; and
(iii) Provides the health care provider a plain
language explanation of how to appeal the decision.
(f) An exemption under subsection (a) of this section
shall remain in effect until the thirtieth day after the date
the health insurer or contracted utilization review entity
notifies the health care provider of its determination to revoke
the exemption or, if the health care provider appeals the
determination, the fifth day after the revocation is upheld on
appeal.
(g) A determination to revoke or deny an exemption under
subsection (a) of this section shall be made by a licensed
health care provider that is of the same or similar specialty as
the health care provider being considered for an exemption and
has experience in providing the service for which the potential
exemption applies.
(h) A health insurer or contracted utilization review
entity shall provide a health care provider that receives an
exemption under subsection (a) of this section a notice that
includes:
(i) A statement that the health care provider
qualifies for an exemption from prior authorization
requirements;
(ii) A list of services for which the exemption
applies; and
(iii) A statement of the twelve (12) month duration
of the exemption.
(j) No health insurer or contracted utilization review
entity shall deny or reduce payment for a health care service
exempted from a prior authorization requirement under this
section, including a health care service performed or supervised
by another health care provider when the health care provider
who ordered such service received a prior authorization
exemption, unless the rendering health care provider:
(i) Knowingly and materially misrepresented the
health care service in request for payment submitted to the
health insurer or contracted utilization review entity with the
specific intent to deceive and obtain an unlawful payment from
the health insurer or contracted utilization review entity; or
(ii) Failed to substantially perform the health care
service.