While recognizing the associated administrative hassles and clinical burdens, here are the top 13 areas that the American Medical Association (AMA) uses to monitor the various State Regulatory requirements placed on Prior Authorization. Each state is unique in how they regulate the Insurance Industry.
Prior authorization is a health plan cost control process by which physicians and other health care providers must qualify for payment coverage by obtaining advance approval from a health plan before a specific service is delivered to the patient.
The AMA and others believe prior authorization is overused and existing processes present significant administrative and clinical concerns. These 12 areas should be reviewed when developing policies and procedures to manage Prior Authorizations.
- State Law Regulating Prior Authorization
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- Section 500.2212c SB 247 (2022)
2. ePA and question set
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- ePA requirements on plans and providers
3. Response Times
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- 9 days for nonurgent until May 31, 2024, and then drops to 7 days. 72 hours for urgent
4. PA length
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- PA is valid for not less than 60 calendar days or for a clinically appropriate duration, whichever is later.
5. Retrospective denials
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- No Reference
6. Data reporting
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- Every year, the plan must report to the department on the department, aggregated trend data related to their PA practices and experience for the prior year: (a) # of PA requests. (b) # of PAs denied. (c) # of appeals received. (d) # of adverse determinations reversed on appeal. (e) Total # PA requests, the # of requests that were not submitted electronically. (f) Top 10 services denied. (g) Top 10 reasons PA requests are denied. On 10/1 every year, dept. aggregates data into reports.
7. Clinical criteria and medical necessity
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- PA requirements are to be based on peer-reviewed clinical review criteria developed either by:
- entity that works directly w/ clinicians (in or outside plan) to develop clinical review criteria, and does not receive direct payments based on the outcome of clinical care decision; or
- Medical specialty organization. Clinical review criteria must: – Consider needs of atypical populations/ diagnoses -Ensure quality of care & access -Be evidence-based -Sufficiently flexible for all deviations from norms (on a case-by-case basis) -Be reevaluated & updated when needed/ at least annually.
8. Notice of new requirements
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- For drugs, the plan must notify providers via the plan’s provider portal of new or amended PA requirements at least 45 days before implementation. For services, must notify at least 60 days before implementation.
9. Transparency
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- Plan to make PA requirements, including written clinical review criteria, readily accessible and conspicuously posted on website.
10. Qualifications of the reviewer
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- Denial upon appeal must be reviewed by a licensed physician, board certified, or eligible in the same specialty as a provider who typically manages the medical condition or provides the service. If plan can’t ID a licensed physician who meets requirements w/o exceeding time limits, plan may use a licensed physician in a similar specialty as considered appropriate, determined by plan.
11. Exceptions/ gold carding
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- Plans must adopt a program that promotes the modification of PA requirements of certain prescription drugs, medical care, or related benefits, based on the performance of the providers w/ respect to adherence to nationally recognized evidence-based medical guidelines and other quality criteria.
12. Peer-to peer/appeal process/ other
- No Reference
This list is ever-changing and should be reviewed prior to implementing any new policy and procedure. We recommend the reaffirmation of existing policy regarding coverage for medically necessary treatment and the creation of a new policy supporting increased review of appeal determinations (beyond medical coding alone) by health plans and providers. There is work to reduce prior authorization requirements that could lead to the unintended and undesired consequence of increased post-payment reviews and therefore suggests reaffirmation of policy addressing concerns related to retrospective payment denials and review.
To learn more about Prior Authorization, please read out blog on Need to Know – Top 12 Minnesota Regulations for Healthcare Prior Authorization
Citation: https://fixpriorauth.org/sites/default/files/2022 12/2022%20Prior%20Authorization%20State%20Law%20Chart.pdf
