Prior authorization for health care services.

Latest bill text (Comm Sub) [PDF]


Prior authorization for health care services. Amends the law on health care service prior authorizations: (1) to establish a standard by which to determine whether a health care service is "medically necessary"; (2) to require that the medical review or utilization review practices of a health plan be governed by this standard of medical necessity; (3) to require a health plan to employ a medical director who is responsible for reviewing and approving the health plan's policies on responses to requests for prior authorization; (4) to require a health plan to establish clear written policies and procedures for prior authorization for health care services; (5) to restrict a health plan's prior authorization requirements applying to: (A) physical medicine or rehabilitation services for a covered individual diagnosed with chronic pain; and (B) rehabilitative or habilitative services, including physical therapy, occupational therapy, and chiropractic services; (6) to provide that, under certain circumstances (including the failure of a health plan to respond to a request within certain time limits), a request for prior authorization is conclusively considered to be approved by the health plan; (7) to require a health plan to provide a procedure under which providers and covered individuals may seek retroactive authorization for health care services that are medically necessary covered benefits; and (8) to prohibit a health plan from denying coverage for a health care service merely because prior authorization was not obtained for the health care service before it was provided to a covered individual if: (A) the health care service would have been a covered benefit if prior authorization had been obtained before the health care service was provided to the covered individual; (B) a determination of medical necessity can be made after the health care service is provided; and (C) it is determined that the health care service was medically necessary. Defines "medically necessary" for use in these provisions.


Authored by Senator Messmer

Fiscal Outlook

Title Description Date View
Fiscal NoteFiscal Note #1: Introduced2024-01-10 Click To View


Date Chamber Action
2024-01-10SenateFirst reading: referred to Committee on Health and Provider Services
2024-01-10SenateAuthored by Senator Messmer