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  • Summary date: Apr 18 2023 - View Summary

    Amends GS 58-50-61 definition of utilization review (a set of formal techniques designed to monitor the use of or evaluate the clinical necessity, appropriateness, efficacy or efficiency of health care services, procedures, providers, or facilities) so that the techniques also include prior authorization. Also amends utilization review technique concurrent review so that it now means a utilization review conducted during a patient’s hospital stay or course of treatment and payment will be made for that service (currently, no reference to payment).  Defines closely related service, course of treatment, prior authorization, and urgent health care service. Amends emergency services to include ambulance and other transportation services. 

    Requires insurers or utilization review organizations (URO) to evaluate clinical review at least annually (currently, just periodically). Sets forth five required criteria for the insurer’s clinical review, including that it be based on nationally recognized medical standards, clinically appropriate, and that it be flexible to allow deviations from the norm when justified on an individual basis to ensure access to care.  Establishes qualifications medical doctors performing a noncertification (i.e., that a proposed course of treatment is not medically necessary) must meet, including that they be in the same specialty as the physician who manages the condition at issue and that the physician has experience with treatment of that condition.  Requires medical doctors to issue noncertifications under the clinical direction of one of the insurer’s medical doctors responsible for the provision of health care services to covered persons (i.e., a person covered by a health plan or one acting on their behalf). Requires that notice be given to a covered person if an insurer is questioning medical necessity and that the person’s provider is given an opportunity to speak with the doctor performing the utilization review determination.  Adds a requirement that an insurer maintain a complete list of health care services for which utilization review is required, including all health care services where utilization review is to be performed by a contracting entity.

    Changes the insurer’s deadline for communicating its decision on a utilization review to a provider from a general three business days after receiving the necessary information to deadlines ranging from 48 hours after receiving all necessary information for non-urgent to health care services to within 60 minutes of receiving a request for emergency services that require immediate post-evaluation or post-stabilization services. Requires insurer to provide coverage necessary to screen and stabilize a person for an emergency service before any evaluation of medical necessity occurs. Sets forth presumption of medical necessity if a provider attests in writing to an insurer within 72 hours of a covered person’s admission that the covered person’s condition required emergency services. Requires an insurer to make a concurrent review determination within 24 hours of obtaining all necessary information. Specifies that an insurer failing to make a determination within the time frames set forth in GS 58-50-61 is deemed to have approved the request. 

    Specifies information that the insurer must communicate to a provider in requesting additional information for a utilization review. Requires an insurer to adjudicate these claims promptly and in line with the deadlines set forth in GS 58-3-225 (prompt claim payments under health benefit plans). Bars retrospective limitation, denial, or restriction of care provided pursuant to a utilization review within 45 business days of the review unless  any of six enumerated exceptions apply, including fraud by the provider, the health care service was not a covered benefit on the date care was provided, or the provider failed to meet the insurer’s timely filing requirements.  

    Requires that additional information be provided in notice provisions of noncertification. Sets forth four qualifications that a medical doctor reviewing appeals must possess, including a license to practice medicine in the State, currently in active practice for at least five years in the same or similar specialty as the physician who typically manages the covered person’s medical care, and who has not been actively involved in making the adverse determination.    

    Requires an insurer to post on its website (1) utilization review requirements described in detail in easily understood language and (2) certain statistics related to its utilization review. Establishes notice and posting requirements for when an insurer changes its utilization review requirements.

    Specifies that a utilization review determination is valid for the entire duration of the approved course of treatment and effective regardless of any change in dosage in medication.

    Sets forth five requirements to ensure continuity of care: (1) On receipt, from a covered person or the covered person's provider, of information documenting a prior utilization review determination, requires an insurer to honor a utilization review determination granted to the covered person from a previous insurer for at least 90 calendar days of a covered person's coverage under a new health benefit plan. Permits, during this 90-day time period, an insurer to perform its own utilization review; (2) if there is a change in coverage or approval criteria for a previously authorized healthcare service then that change will not affect a covered person who received a utilization review determination before the effective date of the change for the remainder of the covered person’s health benefit plan year; (3) requires coverage of a service previously granted under a utilization review if a covered person changes plans provided that the medically necessary services subject to the determination don’t change; (4) if a provider performs a health care service closely related to the service for which approval has already been granted, an insurer may not deny a claim for the closely related service for failure of the provider to seek or obtain a utilization review if the provider had notified the insurer of the performance of the closely related service no later than three business days following the completion of the closely related service, but prior to the submission of the claim for payment for that service; (5) bars insurer from restricting certain benefits related to childbirth.

    Specifies that an insurer may not require a provider to request a utilization review for a health care service in order for the covered person to whom the health care service is being provided to receive coverage if, within the most recent 12-month period, the insurer has issued certifications, or would have issued certifications, for not less than 80% of the utilization review requests submitted by the provider for that health care service. Specifies that this does not apply to utilization review requests pending review by an insurer. Permits an insurer to evaluate whether a provider continues to qualify for this exemption not more than once every 12 months. Clarifies that a provider is not required to request an exemption in order to qualify for an exemption.  Specifies that a provider who does not receive an exemption may request from the insurer at any time, but not more than once per year per service, evidence to support the insurer's decision. Permits a health care provider to appeal an insurer's decision to deny an exemption.

    Only allows an insurer to revoke an exemption at the end of the 12-month period if the insurer does all of the following: (1) makes a determination that the provider would not have met the 80% approval criteria based on a retrospective review of the claims for the particular service for which the exemption applies for the previous three months or for a longer period if needed to reach a minimum of 10 claims for review, (2) provides the provider with the information the insurer relied upon in  making the determination to revoke the exemption, and (3) provides the provider a plain language explanation of how to appeal the decision.

    Specifies time frames for how long an exemption remains in place past an insurer’s decision to revoke the exemption.  Requires that decisions on exemptions be made by providers licensed in the State with the same or similar specialty as the provider being considered for the exemption and with experience in providing the services for which the potential exception applies.

    Provides for notice to providers that receive an exemption.   

    Prevents an insurer from denying or reducing payment for a health care service exempted from a utilization review requirement, including a health care service performed or supervised by another provider when the provider who ordered the service received an exemption, unless the rendering provider (1) knowingly and materially misrepresented the health care service in request for payment submitted to the insurer with the specific intent to  deceive and obtain an unlawful payment from the insurer or (2) failed to substantially perform the health care service.

    Specifies that an insurer is not required to evaluate an existing exemption or is prevented from establishing a longer exemption period.

    Specifies that any failure by an insurer to comply with the deadlines and other requirements specified in GS 58-50-61 will result in any health care services subject to review to be automatically deemed authorized by the insurer.

    Makes technical and conforming changes.  Makes language gender neutral. 

    Effective January 1, 2024, and applies to insurance contracts issued, renewed, or amended on or after that date.

  • Summary date: Apr 17 2023 - View Summary

    To be summarized.