House File 632 H-1227 Amend House File 632 as follows: 1 1. Page 5, after line 31 by inserting: 2 < Sec. ___. NEW SECTION . 505.26A Prior 3 authorization for coverage of health care services —— 4 procedure. 5 1. As used in this section, “adverse determination” , 6 “final adverse determination” , “health benefit plan” , 7 “health care provider” , “health care services” , and 8 “health carrier” mean the same as defined in section 9 514J.102. For purposes of this section, “health care 10 services” does not include prescription drug benefits. 11 2. a. The commissioner shall develop, by rule, a 12 process for use by each health carrier that requires 13 prior authorization for coverage of health care 14 services pursuant to a health benefit plan, providing 15 that if a request for prior authorization of coverage 16 of health care services submitted by a health care 17 provider to a health carrier is not approved or 18 disapproved within seventy-two hours of the health 19 care provider’s submission of the request, the request 20 shall be deemed to be denied by the health carrier 21 and such denial shall be considered a final adverse 22 determination for the purposes of appeal of the prior 23 authorization determination as provided in chapter 24 514J. 25 b. However, if the prior authorization request is 26 incomplete or additional information is required, the 27 health carrier may request the additional information 28 within the seventy-two-hour period and once the 29 additional information is submitted, the provisions of 30 paragraph “a” shall again apply. 31 3. The commissioner shall develop, by rule, a 32 standard prior authorization process for use by each 33 health carrier that requires prior authorization for 34 health care services which meets all of the following 35 requirements: 36 a. Health carriers shall allow health care 37 providers to submit a prior authorization request 38 electronically. 39 b. Health carriers shall make all of the following 40 available and accessible on their internet sites: 41 (1) Prior authorization requirements and 42 restrictions, including a list of health care services 43 that require prior authorization. 44 (2) Clinical criteria that are easily 45 understandable to health care providers. 46 (3) Standards for submitting and considering 47 requests, including evidence-based guidelines, 48 when possible, for making prior authorization 49 determinations. 50 -1- HF632.1489 (2) 86 av/nh 1/ 2 #1.