HEA 1143: Medicaid Prior Authorization Transparency

Prior Authorization (HEA 1143)

Bills were filed in both the House (HEA 1143) and the Senate (SB 210) this year with language modeled on Ohio legislation to streamline the prior authorization process and create more transparency. Bill authors Representative Donna Schaibley (R-Carmel) and Senator Liz Brown (R-Fort Wayne) were strong advocates for the provider community in helping to reach an agreement with insurers.
   
Effective Date Sept. 1, 2018: Transparency and Notice Provisions

• Definition of Prior Authorization: Practice implemented by a health plan through which coverage of a health care service is dependent on the covered individual or health care provider obtaining approval from the health plan before the health care service is rendered. The term includes prospective or utilization review procedures conducted before a health care service is rendered.
• Notice to health care providers of changes in prior authorization procedures is changed from 30 days to 45 days in advance.
• Health plans must make available to providers a list of the health plan’s prior authorization requirements including specific information that a provider must submit to complete a prior authorization request. 

Effective Date Dec. 31, 2018: Unanticipated Services

• Health plan shall not deny payment for services that have received prior authorization.
• For unanticipated services, a retrospective review may be requested only for those services (not the whole claim) and payment may be withheld until the review is complete.

Effective Date Dec. 31, 2019: 

• For urgent care prior authorization requests: Health plan must respond within 72 hours. The health provider must also respond within 72 hours if the PA request is incomplete (no current deadline).
• For non-urgent prior authorization requests: Health Plan must respond within seven days. Currently, under law it is 15 days.
• Health plan must provide specific reason for the denial of a PA request.
• Tightens language regarding when a claim must be paid if prior authorization is requested and approved by the health plan. The claim cannot be denied unless the prior authorization request contained fraudulent or materially incorrect information or the covered individual is not covered under the health plan on the date in which the service was provided.