West Virginia-2018-HB4239-Introduced

ARTICLE 4. GENERAL PROVISIONS.

§33-4-22. Prior authorization.

(a) “Urgent care services” means a medical care or other service for a condition where application of the timeframe for making routine or nonlife threatening care determinations is either of the following:

(1) Could seriously jeopardize the life, health, or safety of the patient or others due to the patient’s psychological state; or

(2) In the opinion of a practitioner with knowledge of the patient’s medical or behavioral condition, would subject the patient to adverse health consequences without the care or treatment that is the subject of the request.

(b) The Governor shall appoint a person who is knowledgeable in the creation of insurance forms to lead a collaborative effort of the Public Employees Insurance Agency, managed care organizations and private commercial insurers to develop universal prior authorization forms accessible through either a computer program, email, app, or secure electronic transmission. The appointee is responsible for the organization of the participants and the creation of the forms approved by the participants. The forms shall include instructions for the universal submission of clinical documentation, and provide an electronic notification confirming receipt of the prior authorization request. The forms shall be prepared by October 1, 2018. The group may develop no more than 8 forms differentiated by the type of service being requested.

(c) Public Employees Insurance Agency, managed care organizations and private commercial insurers, shall accept electronic prior authorization requests and respond to the request through electronic means by July 1, 2019.

(d) If the health care practitioner submits the request for prior authorization electronically, the insurer or plan shall respond to the prior authorization request within 24 hours calendar day for urgent care services, or 168 hours for any prior approval request that is not for an urgent care service, from the time on the electronic receipt of the prior authorization request.

(e) If information submitted is considered incomplete, the health care practitioner shall provide the additional information requested within 72 hours from the time the request is received by the practitioner or the prior authorization is deemed denied and a new request must be submitted.

(f) The Public Employees Insurance Agency, managed care organizations and private commercial insurers shall make available on their websites information about the policies, contracts, or agreements offered that clearly identifies specific services, drugs, or devices to which a prior authorization requirement exists.

(g) A prior authorization approved by a managed care organization is carried over to all other managed care organizations for three months, if the services are provided within the state.

(h) The Public Employees Insurance Agency, managed care organizations and private commercial insurers shall use the Milliman standard to evaluate a prior authorization.

(i) Any provision of a contractual arrangement entered into between an insurer or plan and a health care practitioner or beneficiary that is contrary to this section is unenforceable.

(j) This section is not applicable to submission of a prior authorization request through telephone, mail, or fax.

NOTE: The purpose of this bill is to establish universal forms and establish deadlines when a prior authorization is submitted electronically.

Strike-throughs indicate language that would be stricken from a heading or the present law and underscoring indicates new language that would be added.