Section 376.1364

There are multiple enactments of 376.1364

Title XXIV BUSINESS AND FINANCIAL INSTITUTIONS

Chapter 376

Effective - 28 Aug 2026, 2 histories, see footnote   

  376.1364.  Unique confirmation number required, prior authorization review — secure electronic transmission for prior authorizations — online process, requirements — application interface program, requirements — approval and denial statistics — reports. — 1.  Any utilization review entity performing prior authorization review shall provide a unique confirmation number to a provider upon receipt from that provider of a request for prior authorization.  Except as otherwise requested by the provider in writing, unique confirmation numbers shall be transmitted or otherwise communicated through the same medium through which the requests for prior authorization were made.

  2.  (1)  No later than January 1, 2021, utilization review entities shall accept and respond to requests for prior authorization of drug benefits through a secure electronic transmission using the National Council for Prescription Drugs SCRIPT Standard Version 2017071 or a backwards-compatible successor adopted by the United States Department of Health and Human Services.  For purposes of this subdivision, facsimile, proprietary payer portals, and electronic forms shall not be considered electronic transmission.

  (2)  Beginning July 1, 2028, health carriers shall establish and maintain an online process that:

  (a)  Links directly to all e-prescribing systems and electronic health record systems that utilize the National Council for Prescription Drug Programs SCRIPT standard and the National Council for Prescription Drug Programs Real Time Benefit Standard;

  (b)  Can accept electronic prior authorization requests from a health care provider;

  (c)  Can approve electronic prior authorization requests:

  a.  For which no additional information is needed by the carrier to process the prior authorization requests;

  b.  For which no clinical review is required; and

  c.  That meet the carrier's criteria for approval;

  (d)  Links directly to real time patient out-of-pocket costs for the prescription drug, considering copayment and deductible; and

  (e)  Otherwise meets the requirements of this subsection.

  (3)  No carrier shall:

  (a)  Impose a fee or charge on any person for accessing the online process as required by subdivision (2) of this subsection; or

  (b)  Access, absent provider consent, provider data through the online process other than for the enrollee.

  (4)  No later than July 1, 2028, a carrier shall provide contact information of any third-party vendor or other entity the carrier will use to meet the requirements of subdivision (2) of this subsection to any provider that requests such information.  A carrier that posts such contact information on its website shall be considered to have met the requirements of this subdivision.

  (5)  After July 1, 2028, a carrier that fails to implement and maintain an online process for prior authorization of prescription drugs in accordance with subdivisions (2) to (4) of this subsection shall not require providers to obtain prior authorization for prescription drugs, except as may be specified by the department of commerce and insurance by rule.

  3.  No later than January 1, 2021, utilization review entities shall accept and respond to requests for prior authorization of health care services and mental health services electronically.  For purposes of this subsection, facsimile, proprietary payer portals, and electronic forms shall not be considered electronic transmission.

  4.  By January 1, 2028, health carriers and utilization review entities shall implement and maintain a prior authorization application programming interface (API) that conforms with 45 CFR 156.221(c)(2) through (4), (d), and (e) and the standards in 45 CFR 170.215(a)(1), (b)(1)(i), and (c)(1) to respond to requests for prior authorization for health care services, excluding prescription drugs.  If a health carrier cannot implement the prior authorization API by January 1, 2028, the health carrier shall provide written notice to the department requesting an extension, accompanied by a documented plan to come into compliance.

  5.  By January 1, 2028, an enrollee's health care provider may use the prior authorization API, as described in subsection 4 of this section, to submit requests for prior authorization for health care services, excluding prescription drugs.  A health carrier shall accept prior authorization requests submitted through the prior authorization API.

  6.  For contracts between health carriers and participating health care providers entered into or renewed on or after January 1, 2028, a health carrier may include a provision that requires health care providers to submit prior authorization requests using the application programming interface described in subsection 4 of this section.  If a participating health care provider fails to utilize the prior authorization API to submit requests, cost-sharing for which the enrollee would have otherwise been responsible shall not be affected.

  7.  For plan years beginning on or after January 1, 2027, a health carrier using prior authorization shall make statistics available regarding prior authorization approvals and denials for health care services, excluding drugs, on its website in a readily accessible format.  Health carriers shall submit the uniform resource locator (URL) for the website location where such statistics are posted to the department, and the department shall publish the website locations in a central location on the department's website.  The statistics shall be updated each year thereafter, no later than June thirtieth, and shall include all the following information:

  (1)  The percentage of standard prior authorization requests that were approved, aggregated for all health care services;

  (2)  The percentage of standard prior authorization requests that were denied, aggregated for all health care services;

  (3)  The percentage of prior authorization requests that were approved after appeal, aggregated for all health care services;

  (4)  The percentage of prior authorization requests for which the time frame for review was extended, and the request was approved, aggregated for all health care services;

  (5)  The percentage of expedited prior authorization requests that were approved, aggregated for all health care services;

  (6)  The percentage of expedited prior authorization requests that were denied, aggregated for all health care services;

  (7)  The average and median time that elapsed between the submission of a request and a determination by the health carrier for standard prior authorization, aggregated for all health care services;

  (8)  The average and median time that elapsed between the submission of a request and a decision by the health carrier for expedited prior authorizations, aggregated for all health care services; and

  (9)  Any other information as the department determines appropriate.

  8.  Every health carrier in this state offering a health benefit plan with a managed care component shall report annually to the department, in a manner specified by the department, a complete list of the health care services, excluding drugs, for which prior authorization is required, including for services where prior authorization is performed by the health carrier's utilization review entity.

  9.  Health carriers shall reduce the scope of claims subject to prior authorizations.  To promote consistency among carriers, the department shall review the reports submitted under subsections 8 and 10 of this section and compile an annual report to be published on the department's website no later than October first of each year.

  10.  No later than May 31, 2028, and annually thereafter, every health carrier in this state offering a health benefit plan with a managed care component shall report to the department, in a manner specified by the department, aggregated data related to the following practices and experience of the health carrier for the prior plan year for health care services submitted for payment, excluding drugs:

  (1)  The number of prior authorization requests;

  (2)  The number of prior authorization requests approved;

  (3)  The number of prior authorization requests denied;

  (4)  The number of prior authorization requests for mental health services, behavioral health benefits, and substance use disorders;

  (5)  The number of prior authorization requests for mental health services, behavioral health benefits, and substance use disorders denied;

  (6)  The number of prior authorization requests for mental health services, behavioral health benefits, and substance use disorders approved;

  (7)  The number of prior authorization appeals received;

  (8)  The number of adverse determinations reversed on appeal;

  (9)  The ten health care services or mental health services that were most frequently denied through prior authorization;

  (10)  The most frequent, but no fewer than five, reasons prior authorization requests were denied; and

  (11)  The number of claims for health care services or mental health services that were examined through a postservice utilization review process.

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(L. 2019 S.B. 514, A.L. 2026 H.B. 2372)