Florida Senate - 2023 SB 1434
By Senator Simon
3-01928A-23 20231434__
1 A bill to be entitled
2 An act relating to prior authorization; amending s.
3 627.42392, F.S.; defining terms; redefining the term
4 “health insurer” as “utilization review entity” and
5 revising the definition; requiring utilization review
6 entities to establish and offer a prior authorization
7 process for accepting electronic prior authorization
8 requests; specifying a requirement for the process;
9 specifying additional requirements and procedures for,
10 and restrictions and limitations on, utilization
11 review entities relating to prior authorization for
12 covered health care benefits; defining the term
13 “medications for opioid use disorder”; providing
14 construction; making technical changes; providing an
15 effective date.
16
17 Be It Enacted by the Legislature of the State of Florida:
18
19 Section 1. Section 627.42392, Florida Statutes, is amended
20 to read:
21 627.42392 Prior authorization.—
22 (1) As used in this section, the term:
23 (a) “Adverse determination” means a decision by a
24 utilization review entity that the health care services
25 furnished or proposed to be furnished to an insured are not
26 medically necessary or are experimental or investigational, and
27 benefit coverage is therefore denied, reduced, or terminated. A
28 decision to deny, reduce, or terminate services that are not
29 covered for reasons other than their medical necessity or
30 experimental or investigational nature is not an adverse
31 determination for purposes of this section.
32 (b) “Electronic prior authorization process” does not
33 include transmissions through a facsimile machine.
34 (c) “Emergency health care services” has the same meaning
35 as “emergency services and care” as defined in s. 395.002(9).
36 (d) “Prior authorization” means the process by which a
37 utilization review entity determines the medical necessity or
38 appropriateness, or both, of otherwise covered health care
39 services before the rendering of such health care services. The
40 term also includes any utilization review entity’s requirement
41 that an insured or health care provider notify the utilization
42 review entity before providing a health care service.
43 (e) “Urgent health care service” means a health care
44 service that, if the timeframe for making a nonexpedited prior
45 authorization is applied, in the opinion of a physician with
46 knowledge of the patient’s medical condition, could:
47 1. Seriously jeopardize the life or health of the patient
48 or the ability of the patient to regain maximum function; or
49 2. Subject the patient to severe pain that cannot be
50 adequately managed without the care, treatment, or prescription
51 drug that is the subject of the prior authorization request.
52 (f) “Utilization review entity” “health insurer” means an
53 authorized insurer offering health insurance as defined in s.
54 624.603, a managed care plan as defined in s. 409.962(10), or a
55 health maintenance organization as defined in s. 641.19(12), a
56 pharmacy benefit manager as defined in s. 624.490, or any other
57 individual or entity that provides, offers to provide, or
58 administers hospital, outpatient, medical, prescription drug, or
59 other health benefits under a policy, plan, or contract to a
60 person treated by a health care professional in this state.
61 (2) Beginning January 1, 2024, a utilization review entity
62 must establish and offer a secure, interactive online electronic
63 prior authorization process for accepting electronic prior
64 authorization requests. The process must allow a person seeking
65 prior authorization the ability to upload documentation if such
66 documentation is required by the utilization review entity to
67 adjudicate the prior authorization request.
68 (3) Notwithstanding any other provision of law, effective
69 January 1, 2017, or six (6) months after the effective date of
70 the rule adopting the prior authorization form, whichever is
71 later, a utilization review entity that health insurer, or a
72 pharmacy benefits manager on behalf of the health insurer, which
73 does not provide an electronic prior authorization process for
74 use by its contracted providers, shall use only use the prior
75 authorization form that has been approved by the Financial
76 Services commission for granting a prior authorization for a
77 medical procedure, course of treatment, or prescription drug
78 benefit. Such form may not exceed two pages in length, excluding
79 any instructions or guiding documentation, and must include all
80 clinical documentation necessary for the utilization review
81 entity health insurer to make a decision. At a minimum, the form
82 must include:
83 (a)(1) Sufficient patient information to identify the
84 member, date of birth, full name, and health plan ID number;
85 (b)(2) The provider’s provider name, address, and phone
86 number;
87 (c)(3) The medical procedure, course of treatment, or
88 prescription drug benefit being requested, including the medical
89 reason therefor, and all services tried and failed;
90 (d)(4) Any laboratory documentation required; and
91 (e)(5) An attestation that all information provided is true
92 and accurate.
93 (4)(3) The Financial Services commission, in consultation
94 with the Agency for Health Care Administration, shall adopt by
95 rule guidelines for all prior authorization forms which ensure
96 the general uniformity of such forms.
97 (5)(4) Electronic prior authorization approvals do not
98 preclude benefit verification or medical review by the
99 utilization review entity insurer under either the medical or
100 pharmacy benefits.
101 (6) A utilization review entity’s prior authorization
102 process may not require information that is not needed to make a
103 determination or facilitate a determination of medical necessity
104 of the requested medical procedure, course of treatment, or
105 prescription drug benefit.
106 (7) A utilization review entity shall disclose all of its
107 prior authorization requirements and restrictions, including any
108 written clinical criteria, in a publicly accessible manner on
109 its website. Such information must be explained in detail and in
110 clear and ordinary terms.
111 (8) A utilization review entity may not implement any new
112 requirement or restriction or make changes to existing
113 requirements or restrictions on obtaining prior authorization
114 unless:
115 (a) The changes have been available on a publicly
116 accessible website for at least 60 days before they are
117 implemented; and
118 (b) Insureds and health care providers affected by the new
119 requirements and restrictions or by the changes to the
120 requirements and restrictions are provided with a written notice
121 of the changes at least 60 days before they are implemented.
122 Such notice must be delivered electronically or by other means
123 as agreed to by the insured or the health care provider.
124 (9) A utilization review entity shall make available data
125 regarding prior authorization approvals and denials on its
126 website in a readily accessible format, which must include
127 categories specifying:
128 (a) Physician specialty;
129 (b) Medication or diagnostic test or procedure;
130 (c) The indication offered;
131 (d) The reason for denial, if applicable;
132 (e) If denied, whether the denial was appealed;
133 (f) If a denial was appealed, whether it was approved or
134 denied on appeal; and
135 (g) The time between submission and the response.
136
137 This subsection does not apply to the expansion of health care
138 services coverage.
139 (10) A utilization review entity shall ensure that all
140 adverse determinations are made by a physician licensed pursuant
141 to chapter 458 or chapter 459. The physician must:
142 (a) Possess a current and valid nonrestricted license to
143 practice medicine in this state;
144 (b) Be of the same specialty as the physician who typically
145 manages the medical condition or disease or who provides the
146 health care service involved in the request; and
147 (c) Have experience treating patients with the medical
148 condition or disease for which the health care service is being
149 requested.
150 (11) Notice of an adverse determination must be provided by
151 e-mail to the health care provider that initiated the prior
152 authorization. The notice must include:
153 (a) The name, title, e-mail address, and telephone number
154 of the physician responsible for making the adverse
155 determination;
156 (b) The written clinical criteria, if any, and any internal
157 rule, guideline, or protocol the utilization review entity
158 relied upon in making the adverse determination, and how those
159 provisions apply to the insured’s specific medical circumstance;
160 (c) Information for the insured and the insured’s health
161 care provider which describes the procedure through which the
162 insured or health care provider may request a copy of any report
163 developed by personnel performing the review that led to the
164 adverse determination; and
165 (d) An explanation to the insured and the insured’s health
166 care provider on how to appeal the adverse determination.
167 (12) If a utilization review entity requires prior
168 authorization of a nonurgent health care service, the
169 utilization review entity must make an authorization or adverse
170 determination and notify the insured and the insured’s provider
171 of such service of the decision within 2 business days after
172 obtaining all necessary information to make the authorization or
173 adverse determination. For purposes of this subsection,
174 necessary information includes the results of any face-to-face
175 clinical evaluation or second opinion that may be required.
176 (13) A utilization review entity shall render an expedited
177 authorization or adverse determination concerning an urgent
178 health care service and notify the insured and the insured’s
179 provider of such service of the expedited prior authorization or
180 adverse determination no later than 1 business day after
181 receiving all information needed to complete the review of the
182 requested urgent health care service.
183 (14) A utilization review entity may not require prior
184 authorization for prehospital transportation or for provision of
185 an emergency health care service.
186 (15) A utilization review entity may not require prior
187 authorization for the provision of medications for opioid use
188 disorder. As used in this subsection, the term “medications for
189 opioid use disorder” means the use of medications approved by
190 the United States Food and Drug Administration (FDA), commonly
191 in combination with counseling and behavioral therapies, to
192 provide a comprehensive approach to the treatment of opioid use
193 disorder. Such FDA-approved medications used to treat opioid
194 addiction include, but are not limited to, methadone;
195 buprenorphine, alone or in combination with naloxone; and
196 extended-release injectable naltrexone. Such types of behavioral
197 therapies include, but are not limited to, individual therapy,
198 group counseling, family behavior therapy, motivational
199 incentives, and other modalities.
200 (16) A utilization review entity may not revoke, limit,
201 condition, or restrict a prior authorization if care is provided
202 within 45 business days after the date the health care provider
203 received the prior authorization. A utilization review entity
204 shall pay the health care provider at the contracted payment
205 rate for a health care service provided by the health care
206 provider per a prior authorization unless:
207 (a) The health care provider knowingly and materially
208 misrepresented the health care service in the prior
209 authorization request with the specific intent to deceive and
210 obtain an unlawful payment from the utilization review entity;
211 (b) The health care service was no longer a covered benefit
212 on the day it was provided, and the utilization review entity
213 notified the health care provider in writing of this fact before
214 the health care service was provided;
215 (c) The health care provider was no longer contracted with
216 the insured’s health insurance plan on the date the care was
217 provided, and the utilization review entity notified the health
218 care provider in writing of this fact before the health care
219 service was provided;
220 (d) The health care provider failed to meet the utilization
221 review entity’s timely filing requirements;
222 (e) The authorized service was never performed; or
223 (f) The insured was no longer eligible for health care
224 coverage on the day the care was provided and the utilization
225 review entity notified the health care provider in writing of
226 this fact before the health care service was provided.
227 (17) If a utilization review entity required a prior
228 authorization for a health care service for the treatment of a
229 chronic or long-term care condition, the prior authorization
230 shall remain valid for the length of the treatment and the
231 utilization review entity may not require the insured to obtain
232 a prior authorization again for the health care service.
233 (18) A utilization review entity may not impose an
234 additional prior authorization requirement with respect to a
235 surgical or otherwise invasive procedure, or any item furnished
236 as part of the surgical or invasive procedure, if the procedure
237 or item is furnished during the perioperative period of another
238 procedure for which prior authorization was granted by the
239 utilization review entity.
240 (19) If there is a change in coverage or approval criteria
241 for a previously authorized health care service, the change in
242 coverage or approval criteria may not affect an insured who
243 received prior authorization before the effective date of the
244 change for the remainder of the insured’s plan year.
245 (20) A utilization review entity shall continue to honor a
246 prior authorization it has granted to an insured when the
247 insured changes products under the same carrier.
248 (21) Any failure by a utilization review entity to comply
249 with the deadlines and other requirements specified in this
250 section shall result in any health care services subject to
251 review to be automatically deemed authorized by the utilization
252 review entity.
253 (22) The provisions of this section cannot be waived by
254 contract. Any contractual arrangement or action taken in
255 conflict with this section or that purports to waive any
256 requirement of this section is void.
257 Section 2. This act shall take effect July 1, 2023.