MA H4616

Requires health insurers to publish searchable lists of all items, services, and medications requiring prior authorization on their websites, and prohibits prior authorization requests for unlisted items

Mandates annual reporting to the Division of Insurance on prior authorization approvals, denials, appeal outcomes, and processing times by July 1 each year, with public disclosure by December 1

Prohibits retrospective denial of previously approved authorizations unless based on fraud, limits payment recoupment to 1 year, and requires carriers to respond within 24 hours for urgent requests or the request is automatically approved

Requires prior authorization approvals to remain valid for the duration of treatment or at least 1 year, with 90-day coverage continuation when patients switch plans or when drugs are removed from formularies mid-year

Regulates use of artificial intelligence in utilization review by requiring AI decisions be based on individual patient records, prohibiting AI as the sole basis for denials, and mandating disclosure of AI use to providers and enrollees