FL S1574

Requires utilization review entities to establish secure, interactive, online electronic prior authorization processes by January 1, 2025, and mandates that prior authorization decisions for nonemergency services be made within 2 business days and emergency/urgent services within 1 business day

Prohibits utilization review entities from requiring prior authorization for prehospital transportation, emergency health care services, and medications for opioid use disorder (including methadone, buprenorphine, and naltrexone), and bars them from revoking a prior authorization if care is provided within 45 business days of approval

Requires all adverse prior authorization determinations to be made by a Florida-licensed physician of the same specialty as the treating physician, with written notice including the clinical criteria relied upon and an explanation of the appeals process

Creates section 627.4262 prohibiting payment adjudicators from downcoding health care services billed by in-network providers unless expressly allowed by the participation agreement, requiring medical record review before any downcoding, and granting providers a private cause of action for violations

Amends claims payment rules to shorten the window for retrospective denial due to insured ineligibility from 1 year to 90 days, prohibits insurers from requiring information from providers before the provision of emergency services as a condition of payment, and bars insurers from requesting resubmission of previously provided claim information