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://casetext.com/statute/code-of-alabama/title-27-insurance/chapter-3a-health-care-service-utilization-review-act/section-27-3a-5-standards-for-utilization-review-agents 


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
  • Requires the use of standardized paperwork 
  • 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.
  • Requires utilization review entities to utilize a standardized prior authorization form. 

 

1: https://codes.findlaw.com/az/title-20-insurance/az-rev-st-sect-20-2803.html;
2: https://www.azleg.gov/legtext/55leg/1r/laws/0115.htm
 


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 notice and transparency in adverse determination 
  • 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
  • Requires an adverse determination notice to include a licensed physician’s contact for discussing treatment and decision reasons with the provider. 

1: https://law.justia.com/codes/arkansas/2017/title-23/subtitle-3/chapter-99/subchapter-11/; 
2: https://www.arkleg.state.ar.us/Bills/Detail?id=hb1271&ddBienniumSession=2023%2F2023R


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://casetext.com/regulation/california-code-of-regulations/title-28-managed-health-care/division-1-the-department-of-managed-health-care/chapter-2-health-care-service-plans/article-7-standards/section-130067241-prescription-drug-prior-authorization-or-step-therapy-exception-request-form-process


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
3: https://law.justia.com/codes/colorado/2020/title-10/article-16/section-10-16-124-5/#:~:text=Requires%20carriers%20and%20pharmacy%20benefit,drug%20benefit%20approved%2C%20the%20next


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
  • Limits reauthorization requests for chronic conditions 
  • 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
  • Restricted from demanding prior authorization for a 72-hour supply of non-controlled medication during emergency situations.
  • Forms must inquire if the prescribed medication is for a chronic or long-term condition essential to the patient’s life, and in such cases, the pharmacy benefit manager can only request reauthorization once every 12 months.

1: https://legis.delaware.gov/SessionLaws/Chapter?id=15869


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 transparency in prior authorization criteria 
  • Requires health plans to utilize a standardized prior authorization form.¹
  • Requires health plans to provide healthcare providers with prior authorization criteria within one business day upon request. If a request is denied, the health plan must include the criteria used or guide on accessing them via their website in the denial notification. 

1: https://casetext.com/statute/louisiana-revised-statutes/revised-statutes/title-42-public-officers-and-employees/chapter-12-group-insurance/part-i-administration/section-42812-transparency-in-prior-authorizations


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 request
  • Imposes reporting requirements
  • Prior authorization requirements must be based on peer-reviewed clinical review criteria 
  • Imposes approval duration requirements 
  • Imposes notification requirements for amended prior authorization requirements 
  • Requires that appeals of denials are reviewed by health professionals meeting certain qualifications. 
  • Update text: Requires health plans to act on a nonurgent prior authorization request within 9 days of receiving it (reduced to 7 days, effective May 2024). 
  • Requires health plans to act on an urgent prior authorization request within 72 hours of receiving it. 
  • Requires plans to report to aggregated data related to their prior authorization practices.  
  • Requires prior authorization requirements to be based on peer-reviewed clinical review criteria. 
  • Requires that a prior authorization approval is valid for at least 60 calendar days or for a duration that is clinically appropriate.
  • Plans must notify providers via plan’s provider portal of new or amended prior authorizations requirements, at least 45 days for drugs and 60 days for services, before implemented. 
  • Appeals of denials appeals must be reviewed by an impartial health professional, ensuring no financial interest, no prior involvement in the adverse determination, comprehensive evaluation of clinical aspects, and the option to consult with peers. 

1: http://legislature.mi.gov/doc.aspx?2021-SB-0247


Minnesota

  • Requires published utilization review procedures
  • Mandates a response time for acting on prior authorization requests
  • Prohibits utilization review organizations from retrospectively evoking a prior authorization that has been authorized  
  • Requires utilization review organizations of new or amended prior authorization requirements  
  • Mandates honoring prior authorizations for the first 60 days of coverage by new utilization review organizations 
  • Requires public reporting of prior authorization data. 
  • 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
  • Requires utilization review organizations to act on a nonurgent prior authorization request within 5 days if received electronically and 6 days if received. nonelectronically. Requires utilization review organizations to act on an urgent prior authorization request within 48 hours and must include at least one business day after the request.  
  • Prohibits utilization review organizations from retrospectively evoking a prior authorization that has been authorization unless it was authorized based on fraud or conflict with the law.  
  • Must notify all health plan companies at least 45 days before a new or amended prior authorization requirements takes effect.  
  • Requires utilization review organizations to honor a previous utilization review organization’s prior authorizations for first 60 days of coverage.  
  • Requires utilization review organizations to publish prior authorization request data, including number of requests, the number of adverse determinations, and reasons for denials to publicly accessible website.  

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/
3: https://www.revisor.mn.gov/bills/bill.php?b=Senate&f=SF3204&ssn=0&y=2019


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
  • Limits prior authorization requirements for certain prescription drugs  
  • 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
  • Prohibits prior authorization for a generic prescription drug if it has been prescribed without interruption for the same quantity for 6 months and is not a controlled substance.  
  • Prohibits prior authorization for the same prescription drug if coverage of the prescription drug was approved.  
  • Requires that adverse determinations during prior authorization are made by a physician in the relevant medical condition, while non-adverse determinations do not require a specialist’s involvement. 

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
3: https://leg.mt.gov/bills/2023/SB0399/SB0380_X.pdf


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
  • Prohibits decisions in certain circumstances  
  • Imposes reporting requirements on prior authorization data 
  • 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
  • Prohibits a health insurer from rescinding an authorization for mental health or substance use disorder services that has been authorized. 
  • Requires health plans to act on a prior authorization request within 7 business days of receiving it. 

1: https://law.justia.com/codes/new-mexico/2017/chapter-59a/article-22/section-59a-22-52/
2: https://www.nmlegis.gov/Sessions/23%20Regular/final/SB0273.pdf


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
  • Any Medicaid Drug Utilization Review Board-approved prior authorization program must review drugs on prior authorization within 12 months of placement. 
  • Medicaid Drug Utilization Review Board-approved prior authorization programs must respond within 24 hours to prior authorization requests. 
  • In emergency situations, Medicaid Drug Utilization Review Board-approved prior authorization program must provide a 72-hour supply or more for effective therapy. 
  • Requires health plans to utilize a standardized prior authorization form.¹

1: https://law.justia.com/codes/oklahoma/2022/title-63/section-63-5030-5/


Oregon:

  • Requires the use of standardized paperwork
  • Mandates a response time for acting on prior authorization requests
  • Prohibits retrospective denials 
  • Mandates reporting requirements  
  • Prohibits new or altered requirements without notice  
  • 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
  • Requires that an approved request for coverage of a treatment, other than a prescription drug, is binding on the insurer for 60 days after the date of treatment begins for the reasonable duration of the treatment based on clinical standards, whichever’s later.  
  • Mandates that an approved request for coverage of a prescription drug is binding on the insurer for one year from the treatment start date if: (A) The drug is prescribed as maintenance therapy expected to last at least 12 months based on medical or scientific evidence; (B) The drug continues to be prescribed throughout the 12-month period; (C) The drug is prescribed for a condition within the scope of use approved by the FDA, or it has been proven safe and effective for the enrollee’s medical condition based on clinical practice guidelines from peer-reviewed medical literature. 
  • Requires that prior authorization determinations are binding if obtained no more than 60 days prior to the date the service is provided.  
  • Mandates that coordinated care organizations compile and post annually to the authority’s website a report of prior authorization data, including the number of requests received, request denied, and requests reversed on appeal.  
  • Requires that a physician licensed make all final recommendations regarding coverage of a treatment, drug, device or testing.  
  • Requires that insurers use clinical review criteria that are evidence-based and continuously updated based on new evidence and research. 
  • Prohibits an insurer from altering or implementing new utilization review requirements without giving a 60-day advance notice to all participating providers. 

1: https://olis.oregonlegislature.gov/liz/2021R1/Downloads/MeasureDocument/HB2517/A-Engrossed


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
  • Sets mandatory prior authorization timelines
  • Requires transparency in request denial 
  • Mandates annual review of prior authorization requirements 
  • 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
  • Mandates that a prior authorization is valid for at least six months from approval date (effective 1/2025). 
  • Requires that a prior authorization denial is accompanied with the reasons for the adverse determination and the right to and instructions on how to appeal (effective 1/2025). 
  • Update current text: Requires utilization review agents to act on a prior authorization request within 2 business days of receiving it (modified to seven days for non-urgent requests, and 72 hours for urgent care, starting 1/2025). 
  • Requires health care providers to deem a request approved if not approved or denied by the deadline (effective 1/2025). 
  • Must review prior authorization requirements annually (effective 1/2025). 

1: https://law.justia.com/codes/tennessee/2018/title-56/chapter-6/part-7/
2: https://casetext.com/statute/tennessee-code/title-56-insurance/chapter-7-policies-and-policyholders-33373/part-37-prior-authorization-fairness-act


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://codes.findlaw.com/tx/insurance-code/ins-sect-1369-304.html
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
  • Beginning July 2025, requires carriers to maintain an online process that links directly to electronic records systems that can accept and approve prior authorization requests at no additional costs to the provider. 

 

1: http://lis.virginia.gov/cgi-bin/legp604.exe?151+ful+CHAP0516
2: https://lis.virginia.gov/cgi-bin/legp604.exe?221+ful+CHAP0284+hil


Washington:

  • Requires published utilization review procedures
  • 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 act on a nonurgent prior authorization request within 3 days of submission for electronic requests, and 5 days for non-electronic requests. Requires health plans to act on an urgent prior authorization request within 1 day of submission for electronic requestions, and 2 days for non-electronic requests. 
  • The carrier’s prior authorization requirements must be described in detail and written in easily understandable language. 
  • The carrier shall make its most current prior authorization 8 requirements and restrictions, including the written clinical review criteria, available to providers and facilities in an electronic format upon request.  
  • The prior authorization requirements must be based on peer-reviewed clinical review criteria, evaluated annually, and accommodate new and emerging information related to the appropriateness of clinical criteria with respect to black and indigenous people, other people of color, gender, and underserved populations.  
  • Requires carriers to build and maintain an online prior authorization application process for providers. 

1: https://app.leg.wa.gov/rcw/default.aspx?cite=48.43.016
2: https://lawfilesext.leg.wa.gov/biennium/2023-24/Pdf/Bills/Session%20Laws/House/1357-S2.SL.pdf


West Virginia:

  • Requires published utilization review procedures
  • Requires acceptance of electronic prior authorization requests
  • Mandates a response time for acting on prior authorization requests
  • Prohibits prior authorization requirements for prescription for an inpatient at discharge  
  • 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
  • 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 2 days of receiving it. 
  • Prior authorization appeals must be reviewed by a health care practitioner, similar in specialty, education, and background. 
  • Prohibits prior authorization for any prescription written for an inpatient at the time of discharge, for not less than three days. 
  • Must maintain a comprehensive list of all procedures, services, drugs, devices, treatment, durable medical equipment, and anything else for which the Public Employees Insurance Agency requires a prior authorization. 

1: http://www.wvlegislature.gov/Bill_Status/bills_text.cfm?billdoc=HB2351%20intr.htm&yr=2019&sesstype=RS&i=2351
2: http://www.wvlegislature.gov/Bill_Status/bills_text.cfm?billdoc=sb267%20sub1%20enr.htm&yr=2023&sesstype=RS&i=267

 

*This law only applies to Medicaid.

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