Prior Authorization Enacted Laws


Alabama

  • Requires published utilization review procedures
  • Mandates a response time for acting on prior authorization requests
  • Requires prior authorization requests to be reviewed by a health care provider
  • Requires utilization review entities to act on a prior authorization request within two business days of receiving it.¹
  • Requires prior authorization requests to be reviewed by a licensed physician or in accordance with standards or guidelines approved by a physician.¹
  • Requires utilization review entities to include the principal reason for the determination and the procedures to initiate an appeal in any notification disapproving of a prior authorization request.¹
  • Requires utilization review entities to maintain a written description of the appeal procedure by which an enrollee or their prescriber can seek review of the utilization review agent’s determinations.¹
  • Requires utilization review appeals to be reviewed by a licensed physician of the same specialty as the original prescriber.¹
  • Requires appeals to be completed within 30 days of the appeal being filed.¹
  • Requires utilization review entities to complete expedited appeals within 48 hours of the appeal being filed.¹
  • Requires utilization review entities to maintain a toll-free telephone line.¹

 

1: https://law.justia.com/codes/alabama/2006/20286/27-3a-5.html


Alaska

  • Requires published utilization review procedures
  • Mandates a response time for acting on prior authorization requests
  • Prohibits retrospective denial
  • Requires prior authorization requests to be reviewed by a health care provider
  • Prohibits retroactive prior authorization for a covered medical procedure on the basis of medical necessity unless it is based on incomplete or inaccurate information provided by the prescribing physician.¹
  • Requires health plans to act on a nonurgent prior authorization request within 72 hours of receiving it. Requires health plans to act on an urgent prior authorization request within 24 hours of receiving it.¹
  • Requires adverse utilization review determinations to be made by a licensed health care provider.1
  • Requires health plans to maintain an internal appeals procedure.¹
  • Requires health plans to act on nonurgent internal appeals within 18 business days of receiving written notice of the appeal. Requires health plans to act on urgent internal appeals within 72 hours of receiving written notice of the appeal.¹
  • Requires health plans to review internal appeals with a health care provider who holds the same professional license as the provider treating the covered person.¹
  • Requires external appeal agencies to act on a nonurgent external appeal within 21 business days of the appeal being filed. Requires external appeal agencies to act on an urgent external appeal within 72 hours of the appeal being filed.¹
  • Requires external appeal agencies to consider the opinion of the physician treating the covered person in their determination. Permits external appeal agencies to consider studies that meet professional standards or have been published in peer-reviewed journals, and treatment guidelines provided by government agencies.¹
  • Requires health plans to maintain information on the availability of prescription medications and whether any prescription medications are excluded from coverage. This guide must be updated annually.¹

 

1: https://law.justia.com/codes/alaska/2013/title-21/chapter-21.07/section-21.07.020/


Arizona

  • Requires prior authorization requests to be reviewed by a health care provider
  • Prohibits retrospective denial
  • Prohibits health plans from requiring prior authorization for an initial medical screening examination and any immediately necessary stabilizing treatment.¹
  • Prohibits health plans from requiring prior authorization for emergency ambulance services.¹
  • Requires health plans to maintain a process whereby enrollees and their treating physicians can request prior authorization for any medically necessary care.¹
  • Requires prior authorization request determinations to be made by a physician.¹
  • Prohibits health plans from rescinding or modifying an authorization granted to a specific health care provider after the authorized care is rendered.¹

 

1: https://codes.findlaw.com/az/title-20-insurance/az-rev-st-sect-20-2803.html


Arkansas

  • Requires published utilization review procedures
  • Requires the use of standardized paperwork
  • Mandates a response time for acting on prior authorization requests
  • Requires prior authorization requests to be reviewed by a health care provider
  • Prohibits retrospective denial
  • Requires utilization review entities to disclose all prior authorization requirements and restrictions, including any written clinical criteria, in a publicly accessible manner on their website.¹
  • Requires utilization review entities to have prior authorization requests reviewed by a licensed physician before making an adverse determination.¹
  • Requires utilization review entities to utilize a standardized prior authorization form.¹
  • Requires utilization review entities to act on a nonurgent prior authorization request within 2 business days of receiving it.¹ Requires utilization review entities to act on an urgent prior authorization request within 1 business day of receiving it.¹
  • Prohibits utilization review entities from retrospectively denying pain medication for patients with a terminal illness.¹

 

1: https://law.justia.com/codes/arkansas/2017/title-23/subtitle-3/chapter-99/subchapter-11/


California

  • Requires the use of standardized paperwork
  • Mandates a response time for acting on prior authorization requests
  • Requires utilization review entities to utilize a standardized prior authorization form. Requires health plans to make this form available on their websites.¹
  • Requires health plans to act on a nonurgent prior authorization request within 72 hours of receiving it. Requires health plans to act on an urgent prior authorization request within 24 hours of receiving it.¹
  • If a health plan fails to act on a prior authorization request within the required timeframe, it is deemed approved.¹

1: https://govt.westlaw.com/calregs/Document/I091F75D61BBD487DA203EA0BA0AEECDC?viewType=FullText&originationContext=documenttoc&transitionType=CategoryPageItem&contextData=(sc.Default)


Colorado

  • Mandates a response time for acting on prior authorization requests
  • Requires prior authorization requests to be reviewed by a health care provider
  • Prohibits retrospective denial
  • Requires utilization review entities to include the principal reason for the determination and the procedures to initiate an appeal in any notification disapproving of a prior authorization request.¹
  • Requires second-level internal appeals to be reviewed by a physician.¹
  • Requires health plans to act on a nonurgent prior authorization request within 5 business days of receiving it. Requires health plans to act on urgent prior authorization request within 72 hours of receiving it.²
  • If a health plan fails to act on a prior authorization request within the required timeframe, it is deemed approved.²
  • Requires health plans to honor approved prior authorizations for 180 days.²
  • Prohibits health plans from retroactively denying a prior authorization request once it has been approved.²

 

1: https://codes.findlaw.com/co/title-10-insurance/co-rev-st-sect-10-16-113.html
2: https://leg.colorado.gov/sites/default/files/2019a_1211_signed.pdf


Delaware

  • Requires published utilization review procedures
  • Requires acceptance of electronic prior authorization requests
  • Mandates a response time for acting on prior authorization requests
  • Prohibits retrospective denial
  • Requires utilization review entities to make any prior authorization requirements and restrictions available on their website and available to enrollees upon request. Requires utilization review entities to maintain an electronic prior authorization portal with access to this information.¹
  • Requires utilization review entities to act on a paper prior authorization request within 8 days of receiving it. Requires utilization review entities to act on an electronic prior authorization request within 5 days of receiving it.¹
  • Prohibits utilization review entities from revoking or restricting a prior authorization after approving it.¹

 

1: https://legis.delaware.gov/json/BillDetail/GetHtmlDocument?fileAttachmentId=48363


Florida

  • Requires the use of standardized paperwork
  • Requires health plans and pharmacy benefit managers to use a standardized prior authorization form.¹

 

1: http://laws.flrules.org/2016/224


Georgia

  • Requires the use of standardized paperwork
  • Requires acceptance of electronic prior authorization requests
  • Requires health plans and pharmacy benefit managers to use a standardized prior authorization form.¹
  • Requires health plans and pharmacy benefit managers to accept electronic prior authorization requests.¹

 

1: https://law.justia.com/codes/georgia/2014/title-33/chapter-64/section-33-64-8


Idaho

  • Requires published utilization review procedures
  • Mandates a response time for acting on prior authorization requests
  • Requires prior authorization requests to be reviewed by a health care provider
  • Prohibits retrospective denial
  • Prohibits health plans from requiring prior authorization for emergency services.¹
  • Requires health plans to act on a nonurgent prior authorization request within 2 business days of receiving it.¹
  • Prohibits health plans from rescinding a prior authorization after approving it.¹
  • Requires health plans to adopt utilization management criteria that is based on sound patient care and scientific principles developed in coordination with licensed health care providers.¹
  • Requires health plans to adopt procedures to review a prior authorization request after it has been denied. Requires this review to be conducted by a licensed physician, peer provider, or peer review panel.¹

 

1: https://law.justia.com/codes/idaho/2016/title-41/chapter-39/section-41-3930


Illinois

  • Requires published utilization review procedures
  • Mandates a response time for acting on prior authorization requests
  • Requires health plans to annually provide utilization review procedures and requirements to enrollees and prospective enrollees.¹
  • Requires health plans to act on a nonurgent prior authorization request within 72 hours of receiving it. Requires health plans to act on an urgent prior authorization request within 24 hours of receiving it.¹
  • Prohibits health plans from requiring prior authorization for emergency services.¹

 

1: http://www.ilga.gov/legislation/ilcs/ilcs3.asp?ActID=1265&ChapterID=22


Indiana

  • Requires acceptance of electronic prior authorization requests
  • Requires health plans to accept electronic prior authorization requests.¹

 

1: http://iga.in.gov/legislative/2017/bills/senate/73#document-5a73133e


Iowa

  • Requires published utilization review procedures
  • Requires acceptance of electronic prior authorization requests
  • Mandates a response time for acting on prior authorization requests
  • Requires health plans to publish their prior authorization form online.¹
  • Requires health plans to accept electronic prior authorization requests.¹
  • Requires health plans to publish their prior authorization requirements and restrictions online.¹
  • Requires health plans and pharmacy benefit managers to maintain a process for appealing a prior authorization determination.¹
  • Requires health plans to act on a nonurgent prior authorization request within 5 days of receiving it. Requires health plans to act on an urgent prior authorization request within 72 hours of receiving it.¹

 

1: https://law.justia.com/codes/iowa/2016/title-xiii/chapter-505/section-505.26/


Kentucky

  • Requires published utilization review procedures
  • Requires acceptance of electronic prior authorization requests
  • Mandates a response time for acting on prior authorization requests
  • Requires prior authorization requests to be reviewed by a health care provider
  • Requires health plans to accept electronic prior authorization requests.¹
  • Prohibits health plans from requiring prior authorization for emergency services.¹
  • Requires health plans to honor prior authorizations for 1 year or until the end of the plan year.¹
  • Requires health plans to publish their written utilization review procedures online.¹
  • Prohibits a health plan from requiring prior authorization for a service if the prior authorization procedures were not in place when the service was rendered.¹
  • Requires prior authorization requests to be reviewed by a licensed physician of the same specialty as the original prescriber.¹
  • Requires health plans to act on a nonurgent prior authorization request within 5 business days of receiving it. Requires health plans to act on an urgent prior authorization request within 24 hours of receiving it.¹
  • If a health plan fails to act on a prior authorization request within the required timeframe, it is deemed approved.¹

 

1: https://apps.legislature.ky.gov/recorddocuments/bill/19RS/sb54/bill.pdf


Louisiana

  • Requires the use of standardized paperwork
  • Requires health plans to utilize a standardized prior authorization form.¹

 

1: https://law.justia.com/codes/louisiana/2013/code-revisedstatutes/title-22/rs-22-1006.1/


Maine

  • Requires acceptance of electronic prior authorization requests
  • Mandates a response time for acting on prior authorization requests
  • Requires prior authorization requests to be reviewed by a health care provider
  • Prohibits retrospective denial
  • Requires health plans to appoint a medical director responsible for reviewing and approving utilization review determinations.¹
  • Prohibits health plans from retroactively denying a prior authorization request once it has been approved.¹
  • Prohibits health plans from requiring prior authorization for emergency services.¹
  • Requires health plans to accept electronic prior authorization requests.²
  • Requires health plans to act on a prior authorization request within 48 hours of receiving it.²

 

1: http://legislature.maine.gov/statutes/24-A/title24-Asec4304.html
2: https://legislature.maine.gov/legis/bills/getPDF.asp?paper=SP0218&item=1&snum=129


Maryland

  • Requires the use of standardized paperwork
  • Requires acceptance electronic prior authorization requests
  • Mandates a response time for acting on prior authorization requests
  • Requires health plans to utilize a standardized prior authorization form.¹
  • Requires health plans to publish a list of health care services that require prior authorization.¹
  • Requires health plans to accept electronic prior authorization requests.¹
  • Requires health plans to act on a nonurgent prior authorization request within 2 business days of receiving it. Requires health plans to act on an urgent prior authorization request within 24 hours of receiving it.¹
  • Requires health plans to act on electronic prior authorization requests in real-time.¹

 

1: https://law.justia.com/codes/maryland/2015/article-ghg/title-19/subtitle-1/part-i/section-19-108.2


Massachusetts

  • Requires the use of standardized paperwork
  • Requires acceptance of electronic prior authorization requests
  • Mandates a response time for acting on prior authorization requests
  • Requires health plans to utilize a standardized prior authorization form.¹
  • Requires health plans to make their prior authorization forms available online.¹
  • Requires health plans to accept electronic prior authorization requests.¹
  • Requires health plans to act on a prior authorization request within 2 business days of receiving it.¹
  • If a health plan fails to act on a prior authorization request within the required timeframe, it is deemed approved.¹

 

1: https://malegislature.gov/Laws/GeneralLaws/PartI/TitleXXII/Chapter176O/Section25


Michigan

  • Requires the use of standardized paperwork
  • Mandates a response time for acting on prior authorization requests
  • Requires health plans to utilize a standardized prior authorization form.¹
  • Permits health plans to accept electronic prior authorization requests.¹
  • Requires health plans to act on a nonurgent prior authorization request within 15 days of receiving it. Requires health plans to act on an urgent prior authorization request within 72 hours of receiving it.¹
  • If a health plan fails to act on a prior authorization request within the required timeframe, it is deemed approved.¹

 

1: http://www.legislature.mi.gov/(S(j5lfif3nineoiaqtqly542nf))/mileg.aspx?page=GetObject&objectname=mcl-500-2212c


Minnesota

  • Requires published utilization review procedures
  • Mandates a response time for acting on prior authorization requests
  • Requires utilization review organizations to maintain written policies and criteria for prior authorization requests.¹
  • Requires utilization review organizations to act on a nonurgent prior authorization request within 10 days of receiving it. Requires utilization review organizations to act on an urgent prior authorization request within 72 hours of receiving it.²
  • Requires utilization review entities to include the principal reason for the determination and the procedures to initiate an appeal in any notification disapproving of a prior authorization request.²
  • Prohibits health plans and utilization review organizations from requiring prior authorization for emergency services.¹
  • Requires utilization review organizations to maintain written procedures for appeals.¹

 

1: https://law.justia.com/codes/minnesota/2013/chapters-59a-79a/chapter-62m/section-62m.07/
2: https://law.justia.com/codes/minnesota/2013/chapters-59a-79a/chapter-62m/section-62m.05/


Mississippi

  • Requires the use of standardized paperwork
  • Mandates a response time for acting on prior authorization requests
  • Requires health plans to utilize a standardized prior authorization form.¹
  • Requires health plans to act on a prior authorization request within 2 days of receiving it.¹

 

1: https://law.justia.com/codes/mississippi/2015/title-83/chapter-9/accident-and-health-insurance/section-83-9-63


Missouri

  • Mandates a response time for acting on prior authorization requests
  • Requires health plans to maintain written utilization review procedures.¹
  • Requires health plans to act on a prior authorization request within two business days of receiving it.²
  • Prohibits health plans from requiring prior authorization for emergency services.²

 

1: https://law.justia.com/codes/missouri/2011/titlexxiv/chapter376/section3761359/
2 https://law.justia.com/codes/missouri/2011/titlexxiv/chapter376/section3761363/


Montana

  • Mandates a response time for acting on prior authorization requests
  • Requires health plans to maintain written utilization review procedures.¹
  • Requires health plans to act on a prior authorization request within 7 business days of receiving it.¹
  • Prohibits health plans from requiring prior authorization for emergency services.²

 

1: https://leg.mt.gov/bills/mca/title_0330/chapter_0320/part_0010/section_0030/0330-0320-0010-0030.html
2: https://leg.mt.gov/bills/mca/title_0330/chapter_0320/part_0020/section_0150/0330-0320-0020-0150.html


New Hampshire

  • Requires the use of standardized paperwork
  • Requires acceptance of electronic prior authorization requests
  • Mandates a response time for acting on prior authorization requests
  • Requires health plans to utilize a standardized prior authorization form.¹
  • Requires health plans to accept electronic prior authorization requests.¹
  • Requires health plans to act on an urgent prior authorization request within 48 hours of receiving it.¹

 

1: https://law.justia.com/codes/new-hampshire/2017/title-xxxvii/chapter-420-j/section-420-j-7-b/


New Mexico

  • Requires the use of standardized paperwork
  • Mandates a response time for acting on prior authorization requests
  • Requires health plans to use utilize a standardized prior authorization form.¹
  • Requires health plans to act on a prior authorization request within 3 business days of receiving it.¹
  • If a health plan fails to act on a prior authorization request within the required timeframe, it is deemed approved.¹
  • Prohibits health plans from requiring prior authorization for emergency services.¹

 

1: https://law.justia.com/codes/new-mexico/2017/chapter-59a/article-22/section-59a-22-52/


New York:

  • Requires published utilization review procedures
  • Mandates a response time for acting on prior authorization requests
  • Requires prior authorization requests to be reviewed by a health care provider
  • Requires the use of standardized paperwork*
  • Requires acceptance of electronic prior authorization requests*
    • Requires utilization review agents to appoint a medical director or clinical director, who must be a licensed physician, to oversee the utilization review process.¹
    • Requires utilization review agents to develop written policies and procedures that govern the utilization review process.¹
    • Prohibits utilization review agents from requiring prior authorization for emergency services.¹
    • Requires utilization review agents to have adverse determinations made by a clinical peer reviewer.¹
    • Requires utilization review agents to act on a nonurgent prior authorization request within 3 business days of receiving it.¹
    • If a utilization review agent fails to act on a prior authorization request within the required timeframe, it will be deemed an adverse determination subject to appeal.¹
    • Prohibits utilization review agents from providing compensation or anything of value to its employees that would encourage the rendering of adverse determinations.¹
    • Prohibits utilization review agents from requiring utilization review more frequently than is necessary to assess medical necessity.¹
    • Requires Medicaid Managed Care plans to utilize a standardized prior authorization form.²
    • Requires Medicaid Managed Care plans to accept electronic prior authorization requests.³

 

1: https://www.nysenate.gov/legislation/laws/PBH/A49T1
2: https://newyork.fhsc.com/downloads/providers/nyrx_pdp_pa_fax_standardized.pdf
3: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PDL.pdf


Ohio:

  • Requires published utilization review procedures
  • Mandates a response time for acting on prior authorization requests
  • Requires prior authorization requests to be reviewed by a health care provider
  • Prohibits retrospective denial
  • Requires health plans to maintain their prior authorization policies on their websites.¹
  • Requires health plans to accept electronic prior authorization requests.¹
  • Requires health plans to act on a nonurgent prior authorization request within 10 days of receiving it. Requires health plans to act on an urgent prior authorization request within 48 hours of receiving it.¹
  • Prohibits health plans from retroactively denying a prior authorization under certain conditions.¹
  • Requires health plans to have appeals reviewed by a health care practitioner and a clinical peer.¹

 

1: http://codes.ohio.gov/orc/3923.041


Oklahoma:

  • Requires the use of standardized paperwork
  • Requires health plans to utilize a standardized prior authorization form.¹

 

1: https://law.justia.com/codes/oklahoma/2018/title-63/section-63-313b/


Oregon:

  • Requires the use of standardized paperwork
  • Mandates a response time for acting on prior authorization requests
  • Requires health plans to utilize a standardized prior authorization form.¹
  • Requires health plans to act on a prior authorization request within 2 business days of receiving it.¹

 

1: https://www.oregonlaws.org/ors/743.035


Rhode Island:

  • Mandates a response time for acting on prior authorization requests
  • Requires prior authorization requests to be reviewed by a health care provider
  • Prohibits retrospective denial
  • Requires health plans to act on a nonurgent prior authorization request within 15 business days of receiving it. Requires health plans to act on an urgent prior authorization request within 72 hours of receiving it.¹
  • Prohibits health plans from retrospectively denying a prior authorization after it has been approved.¹
  • Requires health plans to have first-level appeals reviewed by a physician.¹
  • Requires health plans to have second-level appeals reviewed by a physician of the same specialty as the physician treating the covered person.¹

 

1: https://law.justia.com/codes/rhode-island/2018/title-27/chapter-27-18.9/


Tennessee:

  • Requires published utilization review procedures
  • Mandates a response time for acting on prior authorization requests
  • Requires prior authorization requests to be reviewed by a health care provider
  • Requires utilization review agents to act on a prior authorization request within 2 business days of receiving it.¹
  • Requires utilization review agents to make their prior authorization restrictions and requirements available on their online portal.¹
  • Requires utilization review agents to have appeals reviewed by a physician of the same specialty as the physician treating the covered person.¹

 

1: https://law.justia.com/codes/tennessee/2018/title-56/chapter-6/part-7/


Texas:

  • Requires published utilization review procedures
  • Requires the use of standardized paperwork
  • Requires acceptance of electronic prior authorization requests
  • Mandates a response time for acting on prior authorization requests
  • Requires prior authorization requests to be reviewed by a health care provider
  • Requires health plans to utilize a standardized prior authorization form.¹
  • Requires health plans to accept electronic prior authorization requests.¹
  • Requires health plans to post their prior authorization requirements online.²
  • Requires health plans to provide 60 days’ advance notice to enrollees before implementing changes to the plan’s prior authorization requirements.²
  • Requires health plans to have a physician oversee all utilization review activities.²
  • Requires health plans to have internal appeals reviewed by a licensed physician.²
  • Requires health plans to act on a prior authorization request within 3 days of receiving it.³

 

1: https://statutes.capitol.texas.gov/Docs/IN/htm/IN.1369.htm
2: https://capitol.texas.gov/tlodocs/86R/billtext/pdf/SB01742F.pdf#navpanes=0
3: https://codes.findlaw.com/tx/insurance-code/ins-sect-1301-135.html


Utah:

  • Requires published utilization review procedures
  • Requires prior authorization requests to be reviewed by a health care provider
  • Requires health plans to publish information about the drugs and devices subject to prior authorization on their websites.¹
  • Requires health plans to provide 30 days’ advanced notice to enrollees before implementing a change to a prior authorization requirement.¹
  • Requires health plans to have appeals reviewed by a licensed physician, surgeon, or pharmacist.¹

 

1: https://le.utah.gov/~2019/bills/sbillenr/SB0264.pdf


Vermont:

  • Requires the use of standardized paperwork
  • Mandates a response time for acting on prior authorization requests
  • Requires health plans to utilize a standardized prior authorization form.¹
  • Requires health plans to act on a nonurgent prior authorization request within 120 hours of receiving it. Requires health plans to act on an urgent prior authorization request within 48 hours of receiving it.¹
  • If a health plan fails to act on a prior authorization request within the required timeframe, it is deemed approved.¹

 

1: http://www.leg.state.vt.us/docs/2012/Acts/ACT171.pdf


Virginia:

  • Requires published utilization review procedures
  • Requires acceptance of electronic prior authorization requests
  • Requires health plans to publish their prior authorization requirements on their websites.¹
  • Requires health plans to accept electronic prior authorization requests.¹
  • Requires health plans to act on a nonurgent prior authorization request within 2 business days of receiving it. Requires health plans to act on an urgent prior authorization request within 24 hours of receiving it.¹

 

1: http://lis.virginia.gov/cgi-bin/legp604.exe?151+ful+CHAP0516


Washington:

  • Requires published utilization review procedures
  • Requires health plans to publish their prior authorization requirements on their websites.¹

 

1: https://app.leg.wa.gov/rcw/default.aspx?cite=48.43.016


West Virginia:

  • Requires published utilization review procedures
  • Requires acceptance of electronic prior authorization requests
  • Mandates a response time for acting on prior authorization requests
  • Requires health plans to publish their prior authorization requirements on their websites.¹
  • Requires health plans to accept electronic prior authorization requests.¹
  • Requires health plans to act on a nonurgent prior authorization request within 7 days of receiving it. Requires health plans to act on an urgent prior authorization request within 2 days of receiving it.¹

 

1: http://www.wvlegislature.gov/Bill_Status/bills_text.cfm?billdoc=HB2351%20intr.htm&yr=2019&sesstype=RS&i=2351

 

*This law only applies to Medicaid.