§ 9418b. 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) A health plan shall furnish, upon request from a health care provider, a current list of services and supplies requiring prior authorization.

(d) A health plan shall post a current list of services and supplies requiring prior authorization to 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) No 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) No 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 health plan shall respond to a completed prior authorization request from a prescribing health care provider within 48 hours for urgent requests and within two business days of receipt for non-urgent requests. The health plan shall notify a health care provider of or make available to a health care provider a receipt of the request for prior authorization and any needed missing information within 24 hours of receipt. 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. (Added 2007, No. 203 (Adj. Sess.), § 29, eff. June 10, 2008; amended 2009, No. 61, § 31; 2011, No. 171 (Adj. Sess.), § 11h; 2013, No. 79, § 5a, eff. June 7, 2013; 2015, No. 54, § 38.)