CO SB078

Health insurance carriers and private utilization review organizations must offer qualified providers at least one alternative to prior authorization requirements, effective January 1, 2024, including exemptions, incentive awards, or other innovative programs.

Qualified provider status requires continuous participation with the carrier for at least 12 months and at least a 95% approval rate on prior authorization requests for the same health-care service over the preceding 12 months, with a minimum of 24 submitted requests.

Carriers and organizations must annually reexamine providers' prescribing or ordering patterns and reevaluate their qualified provider status, informing providers of their status and providing all data considered in the examination.

The bill applies the same qualified provider requirements and alternatives to drug benefits through pharmacy benefit management firms for prior authorization on prescription drugs.

Disagreements regarding a provider's qualified status must be resolved according to applicable contract provisions, with "same health-care service" defined by unique CPT codes used for care of patients with specific diagnosis codes.