Model Legislation : Prior Authorization Transparency Model Legislation

Model Legislation

Prior Authorization Data Transparency

Burdensome prior authorization requirements frequently prevent Americans from accessing the health care they need. These requirements, which force patients to get their health plans’ approval before receiving services recommended by their doctors, are particularly problematic for individuals seeking mental health or substance use disorder treatment, where delays and denials of treatment can derail treatment and recovery.

An essential step to addressing harmful prior authorization barriers is enhancing transparency, including on denial rates and the use of artificial intelligence.

More than 3 IN 4 DOCTORS reported that prior authorization requirements frequently led their patients to abandon recommended treatment.

State lawmakers can adopt the model language below, taken from the thoroughly vetted Improving Seniors’ Timely Access to Care Act, to establish prior authorization transparency in state-regulated health plans.

Transparency in Prior Authorization Model Act

Every [health insurance / Medicaid managed care] plan that imposes any prior authorization requirement with respect to any applicable item or service during a plan year, shall, beginning with the plan years beginning on or after [DATE], meet the transparency requirements specified in subsection (b).
The plan, annually and in a manner specified by the [Commissioner / Secretary] , shall submit to the [Commissioner / Secretary] the following information:
1. A list of all applicable items and services that were subject to a prior authorization requirement under the plan during the previous plan year.
2. The percentage and number of specified requests approved during the previous plan year by the plan in an initial determination and the percentage and number of specified requests denied during such plan year by such plan in an initial determination (both in the aggregate and categorized by each item and service).
3. The percentage and number of specified requests that were denied during the previous plan year by the plan in an initial determination and that were subsequently appealed.
4. The number of appeals of specified requests resolved during the preceding plan year, and the percentage and number of such resolved appeals that resulted in approval of the furnishing of the item or service that was the subject of such request, categorized by each applicable item and service and categorized by each level of appeal (including judicial review).
5. The percentage and number of specified requests that were denied, and the percentage and number of specified requests that were approved, by the plan during the previous plan year through the utilization of decision support technology, artificial intelligence technology, machine-learning technology, clinical decision-making technology, or any other technology specified by the Secretary.
6. The average and the median amount of time (in hours) that elapsed during the previous plan year between the submission of a specified request to the plan and a determination by the plan with respect to such request for each such item and service, excluding any such requests that were not submitted with the medical or other documentation required to be submitted by the plan.
7. The percentage and number of specified requests that were excluded from the calculation described in subparagraph (8) based on the plan’s determination that such requests were not submitted with the medical or other documentation required to be submitted by the plan.
8. Information on each occurrence during the previous plan year in which, during a surgical or medical procedure involving the furnishing of an applicable item or service with respect to which such plan had approved a prior authorization request, the provider of services or supplier furnishing such item or service determined that a different or additional item or service was medically necessary, including a specification of whether such plan subsequently approved the furnishing of such different or additional item or service.
9. A disclosure and description of any technology described in subparagraph (5) that the plan utilized during the previous plan year in making determinations with respect to specified requests.
10. The number of grievances received by such plan during the previous plan year that were related to a prior authorization requirement.
11. Such other information as the [Commissioner / Secretary] determines appropriate.