SB143 Summary

• Beginning January 1, 2024, all healthcare providers are exempt from prior authorization requirements for six months, unless they increase utilization of a service by 25% or more during the initial exemption period.

• Healthcare providers with a 90% or higher prior authorization approval rate qualify for ongoing exemptions from prior authorization requirements, evaluated annually.

• Healthcare insurers may rescind exemptions only through a retrospective review of random claims samples (5-20 claims) if less than 90% meet medical necessity criteria, with at least 25 days' notice and detailed written explanation to the provider.

• Healthcare providers have the right to independent review of exemption rescissions without requiring internal appeals first, with review completion required within 30 days and all costs paid by the healthcare insurer.

• Healthcare insurers cannot deny or reduce payment for services covered by an exemption based on medical necessity unless the provider knowingly misrepresented the service or substantially failed to perform it; healthcare providers in value-based reimbursement arrangements are exempt from all prior authorization requirements.