Senate committee substitute to the 2nd edition makes the following changes.  Makes technical changes.

Section 2.

Amends GS 131E-214.25 (definitions for new Part 2 of Article 11B of GS Chapter 131E, concerning transparency in healthcare provider billing practices) to remove terms health service facility. Amends GS 131E-214.30 (fair notice requirements) to clarify that a healthcare facility that provides emergency services that would be considered out of network because the facility does not have a contract for services with the insured patient’s insurer must provide the required notice as soon as practicable after the facility begins providing emergency services.  

Removes terms health service facility from GS 58-3-200, as amended by the act. Modifies term healthcare provider so it now just refers to the definition in GS 90-410 (was, any health service facility or any person who is  licensed, registered, or certified under GS Chapter 90 or Chapter 90B, or under the laws of another state, to provide healthcare services in the ordinary care of business or practice, or as a profession, or in an approved education or training program, except that this term does not include a pharmacy). Makes conforming change to GS 131E-214.35 (concerning penalties) to remove health service facilities from the ambit of the statute.

Section 4.

Adds new term ambulatory surgical facility to GS 131E-214.54 (concerning facility fees). Modifies hospital so that it now refers to any hospital as defined in GS 90-176(13) and any facility licensed under GS Chapter 122C (was, as defined in GS 131E-76). Expands the places where facilities fees are allowed to be charged to include an ambulatory surgical facility. Makes organizational and technical changes.

Section 5.

Expands the facilities required to be periodically examined by the State Auditor to include those licensed under GS Chapter 122C that are recipients of State funds. Now requires that the State Auditor report findings to the specified NCGA committee by April 1, 2026, and periodically thereafter as specified.

Section 8.

Adds the following.

Amends GS 58-50-61 (concerning utilization reviews), as follows. Defines an urgent health care service to mean a health care service with respect to which the application of the time periods for making an urgent care determination that, in the opinion of a healthcare provider with knowledge of the covered person's medical condition, either: (1) could seriously jeopardize the person's life or health or their ability to regain maximum function or (2) would subject the person to severe pain that can't be adequately managed without the care or treatment that is subject to utilization review. Defines prior authorization (process by which insurers and utilization review organizations (URO) determine coverage on the basis of medical necessity and/or covered benefits prior to the rendering of those services) and course of treatment.

Creates two different timelines for prospective and current utilization reviews based on the urgency of the healthcare service. Specifies that the current three-business day deadline is for nonurgent healthcare services. For urgent healthcare services, requires the insurer or its utilization review organization (URO) to conduct the review and make the determination or noncertification by not later than 24 hours after receiving the necessary information to conduct the review, unless the reviewer does not have access to the electronic health records of the covered person. Extends the notice obligations pertaining to utilization reviews to URO’s that conduct utilization reviews.   

Sets forth three requirements that apply to an appeals review, including that any appeal not involving a mental health matter be reviewed by a medical doctor meeting the specified criteria, that appeals initiated by a licensed mental health professional be reviewed by either a medical doctor or a licensed mental health professional meeting the prescribed criteria, and the medical doctor or licensed mental health professional to consider all known clinical aspects of the healthcare service under review.  

Requires an insurer to make any current utilization review requirements and restrictions available on its website. Specifies that any new prior authorization requirements or restrictions amendments thereof are not in effect unless and until the insurer’s website has been updated to reflect the new/amended requirements or restrictions. Directs that a claim cannot be denied for failure to obtain a prior authorization if the prior authorization requirement or amended requirement was not in effect on the date of service of the claim.

Sets forth the following requirements that apply to the length of time an approved prior authorization remains valid in certain circumstances:

• If a covered person enrolls in a new health benefit plan offered by the same insurer under which the prior authorization was approved, then the previously approved prior authorization remains valid for the initial 90 days of coverage under the new heath benefit plan. Clarifies that this does not require coverage of a service if it is not a covered service under the new health benefit plan.
• If a healthcare service, other than for in-patient care, requires prior authorization and is for the treatment of a covered person's chronic condition, then the prior authorization shall remain valid for no less than six months from the date the healthcare provider receives notification of the prior authorization approval.

Requires, by January 1, 2028, insurers offering a health benefit plan or a utilization review agent acting on behalf of an insurer offering a health benefit plan, to implement and maintain a prior authorization application programming interface meeting the requirements under 45 C.F.R. § 156.223(b) as it existed on January 1, 2025.

Extends liability for violations of GS 58-50-61 to agents of the insurer. Prevents an insurer from using an artificial intelligence-based algorithm as the sole basis for a utilization review determination.

Applies to insurance contracts, including contracts with URO’s, issued, renewed, or amended on or after October 1, 2026.

Directs the State Treasurer and the Executive Administrator of the State Health Plan to review all practices of the State Health Plan and all contracts with, and practices of, any third party conducting any utilization review on behalf of the State Health Plan to ensure compliance with GS 58-50-61, as amended by the act.