HF 2635

Summary

As enrolled: - Allows utilization review organizations to use artificial intelligence–based algorithms for the initial review of a prior authorization request, but prohibits using AI as the sole basis for denying, delaying, or downgrading a prior authorization request that is based on medical necessity. - Establishes new requirements for health carriers regarding claim payments and audits, including setting payment deadlines, limiting retroactive claim denials, and requiring carriers to reimburse providers for audit-related administrative costs. - Prohibits health carriers from penalizing providers for making out-of-network referrals and from enforcing provider contract terms that were not subject to negotiation. - Requires that a health carrier's denial of a prior authorization request be made by a physician or other health care professional in the same or a similar specialty as the requesting provider. - Exempts certain services from prior authorization requirements, including specified cancer-related screenings and treatment for life-threatening conditions that develop during an inpatient stay. - Requires a health care provider to submit all requests for prior authorization to a health carrier electronically using a standards-based application programming interface, or another form of electronic submission, supported by the health carrier that is compliant with federal interoperability regulations. - Requires a health care provider submitting a request for prior authorization to a MCO to submit the request electronically using a standards-based application programming interface, or another form of electronic submission, supported by the MCO, that is compliant with federal interoperability regulations.

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