Senate File 231 - Introduced SENATE FILE 231 BY COMMITTEE ON HEALTH AND HUMAN SERVICES (SUCCESSOR TO SSB 1016) A BILL FOR An Act relating to prior authorization and utilization review 1 organizations. 2 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA: 3 TLSB 1514SV (3) 91 nls/ko

S.F. 231 Section 1. Section 514F.8, Code 2025, is amended by adding 1 the following new subsections: 2 NEW SUBSECTION . 1A. a. A utilization review organization 3 shall provide a determination to a request for prior 4 authorization from a health care provider as follows: 5 (1) Within forty-eight hours after receipt for urgent 6 requests. 7 (2) Within ten calendar days after receipt for nonurgent 8 requests. 9 (3) Within fifteen calendar days after receipt for 10 nonurgent requests if there are complex or unique circumstances 11 or the utilization review organization is experiencing an 12 unusually high volume of prior authorization requests. 13 b. Within twenty-four hours after receipt of a prior 14 authorization request, the utilization review organization 15 shall notify the health care provider of, or make available to 16 the health care provider, a receipt for the request for prior 17 authorization. 18 c. A utilization review organization shall conduct an annual 19 review and submit the findings in a report to the commissioner 20 pursuant to the reporting procedures and deadlines established 21 by the commissioner. The annual report shall include all of 22 the following: 23 (1) The total number of, and percentage of, urgent prior 24 authorization requests that the utilization review organization 25 approved, aggregated for all health care services and items. 26 (2) The total number of, and percentage of, urgent prior 27 authorization requests that the utilization review organization 28 denied, aggregated for all health care services or items. 29 (3) The total number of, and percentage of, nonurgent prior 30 authorization requests that the utilization review organization 31 approved, aggregated for all health care services or items. 32 (4) The total number of, and percentage of, nonurgent prior 33 authorization requests that the utilization review organization 34 denied, aggregated for all health care services or items. 35 -1- LSB 1514SV (3) 91 nls/ko 1/ 5

S.F. 231 (5) The total number of, and percentage of, nonurgent 1 prior authorization requests that were complex or involved 2 unique circumstances that the utilization review organization 3 approved, aggregated for all health care services or items. 4 (6) The average and median time that elapsed between the 5 submission of a prior authorization request and a determination 6 by the utilization review organization for the prior 7 authorization request, aggregated for all health care services 8 or items. 9 (7) The average and median time that elapsed between the 10 submission of an urgent prior authorization request and a 11 determination by the utilization review organization for the 12 urgent prior authorization request, aggregated for all health 13 care services or items. 14 (8) The average and median time that elapsed between the 15 submission of a nonurgent prior authorization request and a 16 determination by the utilization review organization for the 17 urgent prior authorization request, aggregated for all health 18 care services or items. 19 NEW SUBSECTION . 2A. a. A utilization review organization 20 shall, at least annually, review all health care services for 21 which the health benefit plan requires prior authorization and 22 shall eliminate prior authorization requirements for health 23 care services for which prior authorization requests are 24 routinely approved with such frequency as to demonstrate that 25 the prior authorization requirement does not promote health 26 care quality, or reduce health care spending, to a degree 27 sufficient to justify the health benefit plan’s administrative 28 costs to require the prior authorization. 29 b. (1) A utilization review organization shall submit 30 an annual report containing the findings of the review 31 conducted under paragraph “a” to the commissioner pursuant 32 to the reporting procedures and deadlines established by the 33 commissioner. The annual report shall include all of the 34 following: 35 -2- LSB 1514SV (3) 91 nls/ko 2/ 5

S.F. 231 (a) The total number of prior authorizations the 1 utilization review organization evaluated as part of the annual 2 review. 3 (b) The number of prior authorizations the utilization 4 review organization eliminated as a result of the annual 5 review, and the reason for the elimination. 6 (c) A list of prior authorizations that had at least eighty 7 percent of requests approved in the previous twelve months for 8 a specific health care service covered by a health benefit 9 plan, but which prior authorizations were retained due to 10 medical or scientific evidence, as defined in section 514J.102, 11 that justified continuing such requirement. 12 (d) The total number of prior authorization requests 13 submitted in the previous twelve months for each eliminated 14 prior authorization, and the total number of health care 15 providers that submitted a request for prior authorization 16 in the previous twelve months for each eliminated prior 17 authorization requirement. 18 (e) For each health care service for which prior 19 authorization was eliminated under subparagraph division 20 (b), the report shall include data regarding any increase or 21 decrease of ten percent or greater in the average number of 22 claims submitted per health care provider for that health care 23 service compared to the twelve months immediately preceding the 24 elimination of the prior authorization. 25 (2) The commissioner shall submit an annual report to the 26 general assembly that includes a summary and analysis of the 27 information reported under this paragraph and the information 28 reported under subsection 1A, paragraph “c” . 29 NEW SUBSECTION . 3A. Complaints regarding a utilization 30 review organization’s compliance with this chapter may be 31 directed to the insurance division. The insurance division 32 shall notify a utilization review organization of all 33 complaints regarding the utilization review organization’s 34 noncompliance with this chapter. All complaints received 35 -3- LSB 1514SV (3) 91 nls/ko 3/ 5

S.F. 231 pursuant to this subsection shall not be considered public 1 records for purposes of chapter 22. 2 EXPLANATION 3 The inclusion of this explanation does not constitute agreement with 4 the explanation’s substance by the members of the general assembly. 5 This bill relates to prior authorization and utilization 6 review organizations. 7 The bill requires a utilization review organization 8 (organization) to provide a determination to a request for 9 prior authorization (authorization) from a health care provider 10 (provider) within 48 hours after receipt for urgent requests 11 or within 10 calendar days for nonurgent requests, unless 12 there are complex or unique circumstances, or the organization 13 is experiencing an unusually high volume of authorization 14 requests, then an organization must respond within 15 calendar 15 days. Within 24 hours after receipt of an authorization 16 request, the organization shall notify a provider of, or make 17 available, a receipt for the authorization request. 18 The bill requires an organization to conduct an annual 19 review and submit the findings in a report to the commissioner 20 of insurance (commissioner). The requirements for the 21 report are detailed in the bill. The bill also requires an 22 organization to annually review all health care services for 23 which a health benefit plan (plan) requires an authorization, 24 and to eliminate authorization requirements for health care 25 services for which authorization requests are so routinely 26 approved that the authorization requirement is not justified 27 as it does not promote health care quality or reduce health 28 care spending. An organization shall submit an annual report 29 containing the findings of both reviews to the commissioner, 30 and shall include all of the information detailed in the bill. 31 The commissioner shall submit an annual report to the general 32 assembly containing a summary and analysis of the information 33 in the reports. 34 Complaints regarding an organization’s compliance with 35 -4- LSB 1514SV (3) 91 nls/ko 4/ 5

S.F. 231 the bill may be directed to the insurance division, and 1 the insurance division shall notify an organization of all 2 complaints received regarding the organization. Complaints 3 received under the bill shall not be considered public records. 4 -5- LSB 1514SV (3) 91 nls/ko 5/ 5