Section 23-99-1122 - Denial or rescission of prior authorization exemption(a) A healthcare insurer may rescind an exemption from prior authorization requirements of a healthcare provider under § 23-99-1120 only if:(1) The healthcare insurer makes a determination that, on the basis of a retrospective review of a random sample of claims selected by the healthcare insurer during the most recent evaluation period described by § 23-99-1120(e), less than ninety percent (90%) of the claims for the particular healthcare service met the medical necessity criteria that would have been used by the healthcare insurer when conducting prior authorization review for the particular healthcare service during the relevant evaluation period;(2) The healthcare insurer complies with other applicable requirements specified in this section, including without limitation:(A) Notifying the healthcare provider no less than twenty-five (25) days before the proposed rescission is to take effect; and(B) Providing: (i) An identification of the healthcare service that an exemption is being rescinded, the date the notice is issued, and the effective date of the rescission;(ii) A plain-language explanation of how the healthcare provider may appeal and seek an independent review of the determination, the date the notice is issued, and the company's address and contact information for returning the form by mail or email to request an appeal;(iii) A statement of the total number of payable claims submitted by or in connection with the healthcare provider during the most recent evaluation period that were eligible to be evaluated with respect to the healthcare service subject to rescission, the number of claims included in the random sample, and the sample information used to make the determination, including without limitation: (a) Identification of each claim included in the random sample;(b) The healthcare insurer's determination of whether each claim met the healthcare insurer's screening criteria; and(c) For any claim determined to not have met the healthcare insurer's screening criteria: (1) The principal reasons for the determination that the claim did not meet the healthcare insurer's screening criteria, including, if applicable, a statement that the determination was based on a failure to submit specified medical records;(2) The clinical basis for the determination that the claim did not meet the healthcare insurer's screening criteria;(3) A description of the sources of the screening criteria that were used as guidelines in making the determination; and(4) The professional specialty of the healthcare provider who made the determination;(iv) A space to be filled out by the healthcare provider that includes:(a) The name, address, contact information, and identification number of the healthcare provider requesting an independent review;(b) An indication of whether or not the healthcare provider is requesting that the entity performing the independent review examine the same random sample or a different random sample of claims, if available; and(c) The date the appeal is being requested; and(v) An instruction to the healthcare provider to return the form to the healthcare insurer before the date the rescission becomes effective; and(3) The healthcare provider performs five (5) or fewer of a particular healthcare service in the most recent six-month evaluation period under § 23-99-1120(e).(b) A determination made under subdivision (a)(1) of this section shall be made by a physician who: (1) Possesses a current and unrestricted license to practice medicine in this state; and(2) Has the same or similar specialty as the healthcare provider.(c)(1) A healthcare insurer that is conducting an evaluation under subsection (a) of this section to determine whether or not a healthcare provider still qualifies for a prior authorization exemption may request medical records and documents required for the retrospective review, limited to no more than twenty (20) claims for a particular healthcare service.(2) A healthcare insurer shall provide a healthcare provider at least thirty (30) days to provide the medical records requested under subdivision (c)(1) of this section.(d) A healthcare insurer may deny an exemption from prior authorization requirements under § 23-99-1120 only if:(1) The healthcare provider does not have an exemption at the time of the relevant evaluation period; and(2) The healthcare insurer provides the healthcare provider with:(A) Actual data for the relevant prior authorization request evaluation period; and(B) Detailed information sufficient to demonstrate that the healthcare provider does not meet the criteria for an exemption from prior authorization requirements for the particular healthcare service under § 23-99-1120.(e) A healthcare insurer shall: (1) Allow a healthcare provider to designate an email address or a mailing address for communications regarding exemptions, denials, and rescissions;(2) Provide an option for a healthcare provider to submit a request for an appeal by mail, by email, or by other electronic method; and(3) Include an explanation of how a healthcare provider may update his or her preferred contact information and delivery method on the healthcare insurer's website and for all communications issued under this section.Added by Act 2023, No. 575,§ 5, eff. 8/1/2023.