MI SB1126

Expands mental health and substance use disorder coverage to include inpatient, intermediate, and outpatient care that is medically necessary, with service intensities determined by clinical review criteria from organizations like the American Society of Addiction Medicine and American Psychiatric Association.

Requires insurers to use standardized electronic prior authorization processes for all health benefits including mental health and substance use disorder services, with specific timeframes (7 calendar days for non-urgent requests after May 31, 2024, and 72 hours for urgent requests).

Establishes that level of care determinations for mental health and substance use disorder services must follow American Society of Addiction Medicine, American Psychiatric Association, or other relevant nonprofit professional association clinical review criteria and practice guidelines.

Requires clinical review criteria for prior authorizations to be evidence-based, peer-reviewed, flexible for individual cases, and developed with input from licensed physicians and pharmacists; criteria must be updated at least annually.

Requires insurers to provide detailed denial notifications including reasons, evidence-based criteria used, appeal rights, and necessary documentation for challenging denials of prior authorization requests.