HB 19-1211 Summary

• Establishes requirements for health insurance carriers and utilization review organizations to disclose prior authorization requirements on websites in clear, detailed language with written clinical criteria.

• Requires carriers to notify providers and patients within five business days (or 72 hours for urgent care) whether prior authorization requests are approved, denied, or incomplete; requests are automatically approved if carriers fail to respond within deadlines.

• Mandates carriers post approval/denial data publicly by provider specialty, medication/procedure, denial reasons, and overturned appeals; carriers must use this data to improve utilization management programs.

• Requires prior authorizations to remain valid for at least 180 days and continue throughout the authorized treatment course; carriers cannot retroactively deny previously approved requests except for fraud or coverage changes.

• Allows providers with at least 80 percent prior authorization approval rates over 12 months to qualify for exemptions or alternatives to prior authorization; carriers must reexamine provider patterns annually and notify providers of their exemption status.