This document includes Senate Committee Amendments incorporated into the bill on Tue, Feb 27, 2024 at 10:01 PM by lpoole.
1     
MEDICAL PREAUTHORIZATION AMENDMENTS

2     
2024 GENERAL SESSION

3     
STATE OF UTAH

4     
Chief Sponsor: Jen Plumb

5     
House Sponsor: Robert M. Spendlove

6     

7     LONG TITLE
8     General Description:
9          This bill enacts provisions related to authorization requests.
10     Highlighted Provisions:
11          This bill:
12          ▸     defines terms;
13          ▸     creates deadlines for when a managed care organization must respond to certain
14     authorization requests; and
15          ▸     creates a reporting requirement.
16     Money Appropriated in this Bill:
17          None
18     Other Special Clauses:
19          None
20     Utah Code Sections Affected:
21     ENACTS:
22          31A-45-404, Utah Code Annotated 1953
23     

24     Be it enacted by the Legislature of the state of Utah:
25          Section 1. Section 31A-45-404 is enacted to read:
26          31A-45-404. Timeliness of decisions for preauthorization.
27          (1) As used in this section:

28          (a) "Adverse preauthorization determination" means the same as that term is defined in
29     Section 31A-22-650.
30          (b) "Concurrent request" means a request for medical care while the member is in
31     process of receiving requested medical care or services.
32          (c) "Determination" means a determination by a managed care organization, pharmacy
33     benefit manager, or the managed care organization's designee that, based on the member's
34     benefits and plan's policies, a requested service or medication is approved, denied, or reduced.
35          (d) "Nonurgent request" means a request for medical care, medication, or services
36     where a delay of more than 10 days would not jeopardize an individual's health.
37          (e) "Post-acute services" means services and medical care provided to an individual
38     after discharge from a general acute care hospital including:
39          (i) inpatient rehabilitation;
40          (ii) skilled nursing facility services;
41          (iii) home health;
42          (iv) palliative care;
43          (v) hospice; or
44          (vi) medications required for safe transition of care.
45          (f) "Post-service request" means a request for medical care or services after the care or
46     services have been provided.
47          (g) "Preservice request" means a request for medical care or services prior to an
48     individual receiving the requested care or services.
49          (2) For the following requests from a health care provider for medical care or services
50     on behalf of a member of a managed care organization, the managed care organization shall
51     respond within:
52          (a) for a concurrent request, including for post-acute services:
53          (i) 24 hours from the hour the request is transmitted; or
54          (ii) if the managed care organization requests additional information under Subsection
55     (6), 24 hours from the hour the managed care organization receives the additional information;
56     or
57          (b) for a preservice request that is urgent:
58          (i) 48 hours from the hour the request is transmitted; or

59          (ii) if the managed care organization requests additional information under Subsection
60     (6), 24 hours from the hour the managed care organization received the additional information;
61          (c) for a preservice request that is not urgent, 10 days from the day the request was
62     transmitted; and
63          (d) for a post-service care request, 30 days from the day the request was transmitted.
64          (3) A managed care organization shall complete an appeal from an adverse
65     preauthorization determination in the same amount of time as the time for the applicable
66     request described in Subsection (2).
67          (4) A managed care organization may not deny a post-service request solely because
68     the request for service was initiated after the service was performed.
69          (5) A managed care organization shall report annually to the department the following:
70          (a) percentage of post acute determinations completed within the timelines described in
71     this section;
72          (b) percentage of post acute requests where additional information is requested;
73          (c) the total number of post acute initial requests that were approved and denied,
74     including the percentage; and
75          (d) the total number of post acute appeals that were approved or denied, including the
76     percentage.
77          (6) (a) A managed care organization may request additional information for an
78     authorization request described in this section.
79          (b) For a request described in Subsection (2)(a) or (b), the managed care organization
80     shall submit a request for more information no later than 24 hours after the hour the request is
81     transmitted to the managed care organization.
82          (7) If a managed care organization fails to respond to a request described in Subsection
83     (2) within the time specified, or to request information in accordance with Subsection (6)(b)
84     within the time specified, the request is deemed to be approved.
85          (8) This section only applies to requests from a tertiary hospital or a quaternary
86     hospital.
86a     Ŝ→ (9) This section does not apply to claims filed as part of the Medicaid program. ←Ŝ
87          Section 2. Effective date.
88          This bill takes effect on Ŝ→ [
May 1, 2024] January 1, 2025. ←Ŝ .