Amends TCA Title 53; Title 56 and Title 71.

ON APRIL 10, 2023, THE HOUSE ADOPTED AMENDMENT #1 AND PASSED HOUSE BILL 885, AS AMENDED. AMENDMENT #1 rewrites this bill to enact the Prior Authorization Fairness Act. For purposes of this amendment, "prior authorization" means a written or oral determination made by a health carrier or utilization review organization that an enrollee's receipt of a healthcare service is a covered benefit under the applicable plan and that a requirement of medical necessity or other requirements imposed by such utilization review organization as prerequisites for payment for such services have been satisfied. This amendment applies to all insurers providing a healthcare plan that pays for the provision of healthcare services to covered persons, healthcare plans, and state healthcare plans. This amendment does not apply to healthcare plans that are subject to the exclusive jurisdiction of ERISA, TennCare, or CoverKids. If a utilization review organization makes an adverse determination for a prior authorization of a healthcare service, this amendment requires the carrier or organization to include certain information in the notification to the enrollee and the enrollee's healthcare provider requesting the prior authorization on the enrollee's behalf. This amendment requires that an adverse determination regarding a request for prior authorization for a healthcare service must be made by a licensed physician or a healthcare professional with the same or a similar specialty as the healthcare professional requesting the prior authorization. The requirements for who can make an adverse determination and the notice do not apply to an initial adverse determination for prescription drugs that are covered under an enrollee's benefit plan. The full text of this amendment establishes processes for prior authorization requests and appeals of adverse determinations. Generally, the processes specify deadlines for making coverage decisions under various circumstances. This amendment requires that appeal of prior authorization adverse determinations that are submitted electronically are reviewed or made by a licensed physician or healthcare professional with the same or a similar specialty as the healthcare professional who requested the initial prior authorization. The full text of this amendment specifies additional qualifications for physicians who review or decide appeals. This amendment requires that utilization review organizations perform: (1) A non-urgent prior authorization review within seven calendar days; and (2) An urgent care prior authorization review within 72 hours, plus, if applicable, one additional business day. This amendment prohibits a health carrier or utilization review organization, or a healthcare professional on its behalf, from receiving compensation as an incentive for issuing an adverse decision. A prior authorization adverse determination appeal that is not submitted electronically must be reviewed in accordance with standards set by the National Committee on Quality Assurance. Generally, a prior authorization request, other than an urgent care request, will be deemed approved within seven days, or after the date and time of submission if the carrier or utilization review organization does not act on the request. If a utilization review organization requests that a provider submit additional information, the organization will have five additional days to process the request following the submission of additional information. Subject to certain exceptions specified in the full text of this amendment, a prior authorization request process must not exceed 17 days. Generally, a prior authorization request submitted as an urgent care request by the healthcare provider will be deemed approved by the utilization review organization if the utilization review organization fails to approve or deny the request, or request all additional information needed to make a decision within 72 hours plus, if applicable, one additional business day, after the date and time of submission of the prior authorization request. A health carrier that provides coverage for emergency services in an emergency department of a hospital or freestanding emergency room facility is prohibited from requiring a prior authorization for such emergency services. This amendment requires a healthcare professional to submit a request for a prior authorization at least five calendar days prior to the provision of the service or therapy for non-urgent prior authorizations. Subject to exceptions for inpatient services and certain drugs, this amendment requires that prior authorization for a healthcare service to treat a chronic condition remains valid for at least six months. This amendment requires health carriers to maintain a complete list of healthcare services for which a prior authorization is required. The full text of this amendment also specifies seven requirements for clinical review criteria for healthcare services or prescription drugs requiring prior authorization. This amendment requires that healthcare providers be offered the option of submitting requests for prior authorization electronically. Generally, this amendment requires that prior authorization for an enrollee for a healthcare service is valid for at least six months from the date of approval. This amendment prohibits utilization review organizations and health carriers from requiring prior authorization for prescription drugs used to treat opioid use disorder. The full text of this amendment specifies a process that a utilization review organization must use to implement a new prior authorization requirement, or restriction or amendment to an existing prior authorization requirement. This amendment requires a health carrier or utilization review organization to pay a healthcare provider at the contracted payment rate for a healthcare service provided by the healthcare provider per an approved prior authorization unless: (1) The healthcare provider knowingly and materially misrepresented the healthcare service in the prior authorization request with the specific intent to deceive and obtain an unlawful payment from the health carrier; (2) The healthcare provider was no longer contracted with the patient's health benefit plan on the date the healthcare service was provided; (3) The healthcare provider failed to meet the timely filing requirements of the health carrier; or (4) The health carrier does not have liability for a claim. This amendment also provides the following with regard to payment: (1) A carrier is required to pay a provider for performing a healthcare service if the prior authorization for the service was obtained by another healthcare provider; (2) A carrier is required to provide reimbursement for healthcare services retroactively deemed medically necessary, regardless of when prior authorization was approved, for a maximum period of 18 months; and (3) Payment must be guaranteed when a prior authorization was approved. The full text of this amendment specifies a process for transferring a prior authorization granted to an enrollee from a previous utilization review organization or health carrier to a new health benefit plan. In addition to the foregoing, this amendment addresses provision of services that are closely related to a service for which prior authorization has been granted, responsibility of a health carrier for utilization review activities performed on its behalf by a utilization review organization, provision of statistical data, website notice requirements, and provider notification to a carrier that an enrollee received a service or was admitted to a facility. This amendment specifies that the Prior Authorization Fairness Act applies to utilization review agents under the Health Care Service Utilization Review Act, and original health insurers and successor health insurers. This amendment also specified that the Prior Authorization Fairness Act does not apply to provisions of present law concerning access to health carriers' payment policies and fee schedules. This amendment takes effect upon becoming a law for rulemaking purposes and January 1, 2025, for other purposes, except as unless otherwise specified.