HI HB1525

Requires health carriers and utilization review organizations to certify non-emergency health care services or issue final adverse determinations within two business days for non-urgent services and one business day for urgent services after obtaining necessary information.

Prohibits prospective review requirements for pre-hospital transportation and emergency services, and allows enrollees or providers 24 hours (or until next business day if a holiday/weekend) to notify carriers of emergency admissions.

Mandates that health carriers and utilization review organizations disclose all prospective review requirements, clinical review criteria, and statistical data on certifications and denials organized by physician specialty, medication/procedure, indication, and reason for determination.

Requires notices of adverse determinations to include the reviewing provider's credentials, clinical review criteria applied, and information about appeal procedures and regulatory complaint processes, with special instructions for step therapy or fail-first protocol overrides.

Prohibits carriers from revoking certifications within 45 working days and voids any contract provisions attempting to waive prospective review protections; amends the definition of "medically necessary" to exclude services primarily for the economic benefit of carriers or for provider convenience.