Missouri Senate

Introduced

An exemption under this act shall remain in effect until: the 30th day after the health carrier or utilization review entity notifies the provider of its decision to rescind the exemption as provided in the act, if the provider does not request a review of the decision as specified in the act; or the 5th day after the independent review organization affirms the determination to rescind the exemption, if the provider requests a review of the decision as specified in the act. If a health carrier or utilization review entity does not finalize a rescission determination in one of these manners, the provider shall be considered to have met the criteria for an exemption, and the exemption shall remain in effect. (Section 376.2104)

A health carrier or utilization review entity shall rescind a prior authorization provider exemption only during January or July of each year, if the carrier or utilization review entity makes a determination that less than 90% of a random sample of 5 to 20 claims for the particular health care service met the medical necessity criteria used for prior authorization review, if the carrier or utilization review entity notifies the provider not less than 25 days before the proposed rescission is to take effect, and if the carrier or utilization review entity provides along with this notice both the sample information used to make the determination and a plain language explanation of how the provider may request an independent review of the determination. (Section 376.2106.1). A rescission determination must be made by an individual licensed to practice medicine in this state. A rescission determination made with regard to a physician must be made by an individual licensed to practice medicine in this state who has the same or similar specialty as that physician. (Section 376.2106.2). A health carrier or utilization review entity shall deny a prior authorization provider exemption only if the provider does not have an exemption at the time of the relevant evaluation period, and the carrier or utilization review entity provides the provider with data and information for the relevant evaluation period sufficient to demonstrate that the provider does not meet the criteria for the exemption. (Section 376.2106.3)

Providers shall have the right to a review of an adverse determination regarding a prior authorization provider exemption, which shall be conducted by an independent review organization. No health carrier or utilization review entity shall require a provider to engage in an internal appeals process before requesting a review by an independent review organization. (Section 376.2108.1). A health carrier or utilization review entity shall pay for any appeal or independent review of an adverse determination regarding an exemption under this act, and shall pay a reasonable fee for any copies of medical records or other documents requested from a provider during an independent review requested under the act. (Section 376.2108.2). An independent review organization shall complete a review of an adverse determination regarding an exemption under this act not later than the 30th day after the provider files the request for an independent review. (Section 376.2108.3). A provider may request that the independent review organization consider another random sample of 5 to 20 claims submitted by the provider during the relevant evaluation period for the relevant health care service, as specified in the act. If the provider makes this request, the independent review organization shall base its determination on both the claims initially reviewed by the health carrier or utilization review entity and the claims included in the additional random sample requested by the provider. (Section 376.2108.4)

A health carrier or utilization review entity shall be bound by an independent review determination under the act which does not affirm the determination made by the carrier or entity to deny or rescind a prior authorization provider exemption. (Section 376.2110.1). No health carrier or utilization review entity shall retroactively deny coverage for a health care service on the basis of a rescission of a prior authorization provider exemption, even if the carrier's or entity's determination to rescind the exemption is affirmed by an independent review organization. (Section 376.2110.2). If a health carrier's or utilization review entity's determination of a prior authorization provider exemption is overturned on review by an independent review organization, the carrier or utilization review entity shall not attempt to rescind the exemption before the end of the next evaluation period that occurs, and shall only rescind the exemption thereafter in compliance with the act. (Section 376.2110.3)

After a final determination or review affirming the rescission or denial of a prior authorization provider exemption, a provider shall be eligible for consideration for an exemption for the same health care service after the evaluation period that follows the evaluation period which formed the basis of the rescission or denial. (Section 376.2112)

No health carrier or utilization review entity shall deny or reduce payment to a provider for a health care service for which the provider has a prior authorization provider exemption in effect based on medical necessity or appropriateness of care, unless the provider knowingly and materially misrepresented the health care service in a request for payment with the specific intent to deceive and obtain an unlawful payment, or failed to substantially perform the health care service. (Section 376.2114.1). No health carrier or utilization review entity shall conduct a retrospective review of a health care service subject to a prior authorization provider exemption, except to determine whether the provider still qualifies for the exemption, or if the health carrier or utilization review entity has reasonable cause to suspect there has been a knowing material misrepresentation or a failure to perform the health care service, as specified in the act. (Section 376.2114.2). For retrospective reviews subject to a prior authorization provider exemption, nothing in the act shall be construed to modify existing utilization review procedures or timelines, or any other applicable law except to prescribe when a retrospective utilization review may occur as specified in the act, or when payment may be denied or reduced as specified in the act. (Section 376.2114.3). No later than 5 days after a provider qualifies for a prior authorization provider exemption, a health carrier or utilization review entity shall provide to the provider a notice that includes a statement that the provider qualifies for the exemption, a list of the health care services and health benefit plans to which the exemption applies, and a statement of the duration of the exemption. (Section 376.2114.4). If a provider submits a prior authorization request for a health care service for which the provider qualifies for an exemption, the health carrier or utilization review entity shall include in its response a notice to the provider which includes the information provided to providers when they qualify for an exemption, and a notification of the health carrier's or utilization review entity's payment requirements. (Section 376.2114.5). Nothing in this act shall be construed to authorize provision of health care services outside the scope of providers' applicable licenses, or to require a health carrier or utilization review entity to pay for such services performed outside the scope of a providers' licenses. (Section 376.2114.6)

ERIC VANDER WEERD