SB17-151 Summary

• Requires health insurance carriers and intermediaries conducting credentialing, utilization management, or utilization review to base coverage authorizations and medical necessity determinations on generally accepted, evidence-based standards and criteria of clinical practice.

• Mandates carriers and intermediaries disclose in writing to policyholders and providers the evidence-based standards and processes used for coverage authorizations and medical necessity determinations.

• Requires that coverage authorizations and medical necessity determinations be performed by a licensed health care provider in a similar health field as the requesting provider.

• Prohibits intermediaries from requiring prior authorization for evaluation and management services during an initial health care visit, and prohibits carriers from creating financial incentives to reduce or deny coverage authorizations.

• Establishes a 30-day episode of care threshold, treating a condition as a new episode if the same provider has not treated the policyholder for that condition within the previous 30 days; becomes effective August 9, 2017, subject to referendum petition procedures.