HI HB857

Requires all accident and health insurers, mutual benefit societies, and health maintenance organizations operating in Hawaii to align their prior authorization policies, procedures, and criteria with Medicare guidelines, effective for policies issued or renewed after December 31, 2025.

Establishes mandatory decision timeframes: urgent requests must be approved or denied within 24 hours; non-urgent requests within 3 calendar days; requests are automatically deemed approved if insurers fail to respond within required timeframes.

Requires approval criteria based on nationally recognized evidence-based guidelines and Medicare's medical necessity standards; limits required documentation to Medicare levels; and sets prior authorization duration at 90 days or entire course of treatment, whichever is longer.

Prohibits retroactive denial of payment for previously authorized services, medications, or procedures except in cases of fraud, intentional misrepresentation, or non-compliance with explicitly stated policy terms.

Establishes administrative appeal process allowing policyholders and health care providers to request peer-to-peer review and file complaints with the insurance commissioner within 60 days for administrative hearings.