Section 41-145-NEW-005 - [Newly enacted section not yet numbered] [Effective 7/1/2024] Disclosure and review of prior authorization requirements(1) A health insurance issuer shall maintain a complete list of services for which prior authorization is required, including for all services where prior authorization is performed by an entity under contract with the health insurance issuer.(2) A health insurance issuer shall make any current prior authorization requirements and restrictions, including the written clinical review criteria, readily accessible and conspicuously posted on its website to enrollees, health care professionals and health care providers. Content published by a third party and licensed for use by a health insurance issuer may be made available through the health insurance issuer's secure, password-protected website so long as the access requirements of the website do not unreasonably restrict access. Requirements shall be described in detail, written in easily understandable language, and readily available to the health care professional and health care provider at the point of care. The website shall indicate for each service subject to prior authorization: (a) When prior authorization became required for policies issued or health benefit plan documents delivered in Mississippi, including the effective date or dates and the termination date or dates, if applicable, in Mississippi;(b) The date the Mississippi-specific requirement was listed on the health insurance issuer's, health benefit plan's, or private review agent's website;(c) Where applicable, the date that prior authorization was removed for Mississippi; and(d) Where applicable, access to a standardized electronic prior authorization request transaction process.(3) The clinical review criteria must: (a) Be based on nationally recognized, generally accepted standards except where state law provides its own standard;(b) Be developed in accordance with the current standards of a national medical accreditation entity;(c) Ensure quality of care and access to needed health care services;(e) Be sufficiently flexible to allow deviations from norms when justified on a case-by-case basis; and(f) Be evaluated and updated, if necessary, at least annually.(4) A health insurance issuer shall not deny a claim for failure to obtain prior authorization if the prior authorization requirement was not in effect on the date of service on the claim.(5) A health insurance issuer shall not deem as incidental or deny supplies or health care services that are routinely used as part of a health care service when:(a) An associated health care service has received prior authorization; or(b) Prior authorization for the health care service is not required.(6) If a health insurance issuer intends either to implement a new prior authorization requirement or restriction or amend an existing requirement or restriction, the health insurance issuer shall provide contracted health care professionals and contracted health care providers of enrollees written notice of the new or amended requirement or amendment no less than sixty (60) days before the requirement or restriction is implemented. Written notice may take the form of a conspicuous notice posted on the health insurance issuer's public website or portal for contracted health care professionals and contracted health care providers. A health insurance issuer shall provide email notices to health care professionals or health care providers if the health care professional or health care provider has requested to receive the notice through email. The health insurance issuer shall ensure that the new or amended requirement is not implemented unless the health insurance issuer's website has been updated to reflect the new or amended requirement or restriction. Written notice of a new, amended, or restricted prior authorization requirement, as required by this subsection (6), may be provided less than sixty (60) days in advance if a health insurance issuer determines and contemporaneously notifies the department in writing that:(a) The health insurance issuer has identified fraudulent or abusive practices related to the health care service;(b) The health care service is unavailable or scarce which necessitates the use of an alternative health care service;(c) The health care service is newly introduced to the health care market and a delay in providing coverage for the health care service and would not be in the best interests of enrollees;(d) The health care service is the subject of a clinical trial authorized by the United States Food and Drug Administration; or(e) Changes to the health care service or its availability are otherwise required by law to be made by the health insurance issuer in less than sixty (60) days.(7) Health insurance issuers using prior authorization shall make statistics available regarding prior authorization approvals and denials on their website in a readily accessible format. Following each calendar year, the statistics must be updated annually, by March 31, and include all of the following information: (a) A list of all health care services, including medications, that are subject to prior authorization;(b) The percentage of standard prior authorization requests that were approved, aggregated for all items and services;(c) The percentage of standard prior authorization requests that were denied, aggregated for all items and services;(d) The percentage of prior authorization requests that were approved after appeal, aggregated for all items and services;(e) The percentage of prior authorization requests for which the timeframe for review was extended, and the request was approved, aggregated for all items and services;(f) The percentage of expedited prior authorization requests that were approved, aggregated for all items and services;(g) The percentage of expedited prior authorization requests that were denied, aggregated for all items and services;(h) The average and median time that elapsed between the submission of a request and a determination by the payer, plan or health insurance issuer, for standard prior authorization, aggregated for all items and services;(i) The average and median time that elapsed between the submission of a request and a decision by the payer, plan or health insurance issuer, for expedited prior authorizations, aggregated for all items and services; and(j) Any other information as the department determines appropriate.Miss. Code § 41-145-NEW-005
Added by Laws, 2024, ch. 302, SB 2140,§ 5, eff. 7/1/2024.