Section 9418b - [Effective 1/1/2025] Prior authorization(a) Health plans shall pay claims for health care services for which prior authorization was required by and received from the health plan, unless: (1) the insured was not a covered individual at the time the service was rendered;(2) the insured's benefit limitations were exhausted;(3) the prior authorization was based on materially inaccurate information from the health care provider;(4) the health plan has a reasonable belief that fraud or other intentional misconduct has occurred; or(5) the health plan determines through coordination of benefits that another health insurer is liable for the claim.(b) Notwithstanding the provisions of subsection (a) of this section, nothing in this section shall be construed to prohibit a health plan from denying continued or extended coverage as part of concurrent review, denying a claim if the health plan is not primarily obligated to pay the claim, or applying payment policies that are consistent with an applicable law, rule, or regulation.(c)(1)(A) Except as provided in subdivision (B) of this subdivision (1), a health plan shall not impose any prior authorization requirement for any admission, item, service, treatment or procedure ordered by a primary care provider.(B) The prohibition set forth in subdivision (A) of this subdivision (1) shall not be construed to prohibit prior authorization requirements for prescription drugs or for an admission, item, service, treatment, or procedure that is provided out-of-network.(2) As used in this subsection, "primary care provider" has the same meaning as is used by the Vermont Blueprint for Health.(d)(1) A health plan shall furnish, upon request from a health care provider, a current list of services and supplies requiring prior authorization.(2) A health plan shall make a current list of services and supplies requiring prior authorization available to the public on the insurer's website.(e) In addition to any other remedy provided by law, if the Commissioner finds that a health plan has engaged in a pattern and practice of violating this section, the Commissioner may impose an administrative penalty against the health plan of no more than $500.00 for each violation and may order the health plan to cease and desist from further violations and order the health plan to remediate the violation. In determining the amount of penalty to be assessed, the Commissioner shall consider the following factors:(1) the appropriateness of the penalty with respect to the financial resources and good faith of the health plan;(2) the gravity of the violation or practice;(3) the history of previous violations or practices of a similar nature;(4) the economic benefit derived by the health plan and the economic impact on the health care facility or health care provider resulting from the violation; and(5) any other relevant factors.(f) Nothing in this section shall be construed to prohibit a health plan from applying payment policies that are consistent with applicable federal or State laws and regulations or to relieve a health plan from complying with payment standards established by federal or State laws and regulations.(g)(1)(A) Notwithstanding any provision of law to the contrary, on and after March 1, 2014, when requiring prior authorization for prescription drugs, medical procedures, and medical tests, a health plan shall accept for each prior authorization request either: (i) the national standard transaction information, such as HIPAA 278 standards, for sending or receiving authorizations electronically; or(ii) a uniform prior authorization form developed pursuant to subdivisions (2) and (3) of this subsection (g).(B) A health plan shall have the capability to accept both the national standard transaction information and the uniform prior authorization forms developed pursuant to subdivisions (2) and (3) of this subsection (g).(2)(A) Not later than September 1, 2013, the Department of Financial Regulation shall develop a clear, uniform, and readily accessible prior authorization form for prior authorization requests for medical procedures and medical tests.(B) Not later than September 1, 2013, the Department of Financial Regulation shall develop clear, uniform, and readily accessible forms for prior authorization requests for prescription drugs after determining the appropriate number of forms.(3) Each uniform prior authorization form developed pursuant to subdivision (2) of this subsection shall meet the following criteria, where applicable:(A) The form shall include the core set of common data requirements for nonclinical information for prior authorization included in the HIPAA 278 standard transaction, national standards for prior authorization and electronic prescriptions, or both. The Department shall revise the form as needed to ensure that national standards are adopted and incorporated as soon as such standards are available and final.(B) The form shall be made available electronically by the Department and by the health plan.(C) The completed form or its data elements may be submitted electronically from the prescribing health care provider to the health plan.(D) The Department shall develop the form in consultation with the Department of Vermont Health Access and with input from interested parties from at least one public meeting.(E) The Department shall consider input on the proposed form from the national ASC X-12 workgroup, if available.(F) In developing the uniform prior authorization forms, the Department shall take into consideration the following:(i) existing prior authorization forms established by the federal Centers for Medicare and Medicaid Services, by the Department of Vermont Health Access, and by insurance and Medicaid departments and agencies in other states; and(ii) national standards related to electronic prior authorization.(4)(A)(i) For urgent prior authorization requests, a health plan shall approve, deny, or inform the insured or health care provider if any information is missing from a prior authorization request from an insured or a prescribing health care provider within 24 hours following receipt.(ii) If a health plan informs an insured or a health care provider that more information is necessary for the health plan to make a determination on the request, the health plan shall have 24 hours to approve or deny the request upon receipt of the necessary information.(B) For nonurgent prior authorization requests: (i) A health plan shall approve or deny a completed prior authorization request from an insured or a prescribing health care provider within two business days following receipt.(ii) A health plan shall acknowledge receipt of the prior authorization request within 24 hours following receipt and shall inform the insured or health care provider at that time if any information is missing that is necessary for the health plan to make a determination on the request.(iii) If a health plan notifies an insured or a health care provider that more information is necessary pursuant to subdivision (ii) of this subdivision (4)(B), the health plan shall have 24 hours to approve or deny the request upon receipt of the necessary information.(C) If a health plan does not, within the time limits set forth in this section, respond to a completed prior authorization request, acknowledge receipt of the request for prior authorization, or request missing information, the prior authorization request shall be deemed to have been granted.(D) Prior authorization approval for a prescribed or ordered treatment, service, or course of medication shall be valid for the duration of the prescribed or ordered treatment, service, or course of medication or one year, whichever is longer; provided, however, that for a prescribed or ordered treatment, service, or course of medication that continues for more than one year, a health plan shall not require renewal of the prior authorization approval more frequently than once every five years.(E) For an insured who is stable on a treatment, service, or course of medication, as determined by a health care provider, that was approved for coverage under a previous health plan, a health plan shall not restrict coverage of that treatment, service, or course of medication for at least 90 days upon the insured's enrollment in the new health plan.(h)(1) A health plan shall review the list of medical procedures and medical tests for which it requires prior authorization at least annually and shall eliminate the prior authorization requirements for those procedures and tests for which such a requirement is no longer justified or for which requests are routinely approved with such frequency as to demonstrate that the prior authorization requirement does not promote health care quality or reduce health care spending to a degree sufficient to justify the administrative costs to the plan.(2) A health plan shall attest to the Department of Financial Regulation and the Green Mountain Care Board annually on or before September 15 that it has completed the review and appropriate elimination of prior authorization requirements as required by subdivision (1) of this subsection.Amended by 2024, No. 111,§ 4, eff. 1/1/2025.Amended by 2024, No. 111,§ 3, eff. 1/1/2025, app. to all health plans issued on and after that date, to all health care provider contracts entered into or renewed on and after that date, and to all claims processed on and after that date.Amended by 2023 , No. 6, § 232, eff. 7/1/2023.Added 2007, No. 203 (Adj. Sess.), § 29, eff. 6/10/2008; amended 2009 , No. 61, § 31; 2011, No. 171 (Adj. Sess.), § 11h; 2013 , No. 79, § 5a, eff. 6/7/2013; 2015 , No. 54, § 38; 2019, No. 140 (Adj. Sess.) , § 8, eff. 7/6/2020.This section is set out more than once due to postponed, multiple, or conflicting amendments.