Revises provisions relating to prior authorization. (BDR 57-825)

Existing law authorizes certain health insurers to require prior authorization before an insured may receive coverage for medical and dental care in certain circumstances. If an insurer requires prior authorization, existing law requires the insurer to: (1) file its procedure for obtaining prior authorization with the Commissioner of Insurance for approval; and (2) respond to a request for prior authorization within 20 days after receiving the request. (NRS 687B.225) Sections 27 and 45 of this bill require private insurers and insurers providing coverage for recipients of Medicaid and the Children's Health Insurance Program, respectively, to respond to a request for prior authorization within 2 business days after receiving the request, unless certain nationally recognized operating rules governing prior authorization would allow the insurer to have additional time to respond to the particular request. In such a case, sections 27 and 45 authorize an insurer to respond to the request within the period of time prescribed by the operating rules, unless doing so would result in the insurer responding to the request more than 7 calendar days after receiving the request. Sections 19 and 48 of this bill prohibit insurers from requiring an insured to obtain prior authorization for: (1) certain preventive care services; (2) hospice care provided to pediatric patients; and (3) care provided to treat neonatal abstinence syndrome. Section 19 additionally prohibits insurers, other than those covering recipients of Medicaid or the Children's Health Insurance Program, from requiring prior authorization for: (1) outpatient services for the treatment of substance use disorder; and (2) the prescription of test strips for measuring blood glucose in persons with diabetes. Section 27 makes conforming changes to clarify that a private insurer may not require prior authorization where prohibited by section 19. Sections 4-15 and 35-42 of this bill define certain terms relating to the process of obtaining and processing requests for prior authorization, and sections 2 and 34 of this bill establish the applicability of those definitions. Section 23 of this bill provides that if a private insurer violates any provision of section 19 or 27 with respect to a particular request for prior authorization, that the request is deemed approved. Section 28 of this bill requires a nonprofit hospital and medical or dental service corporation to comply with sections 2-26 of this bill. Section 29 of this bill requires the Director of the Department to administer the provisions of sections 33-52 of this bill in the same manner as other provisions governing Medicaid. Section 56 of this bill requires plans of self-insurance for private employers, respectively, to comply with the requirements of sections 19 and 27 to the extent applicable. Section 15.5 of this bill provides that a health maintenance organization or other managed care organization that provides services to recipients of Medicaid or the Children's Health Insurance Program or members of the Public Employees' Benefits Program, or a utilization review organization that conducts utilization reviews for such entities, is not subject to sections 2-27.