S.F. No. 3204 - Summary

• Modifies utilization review and prior authorization requirements for health insurance plans by replacing "certification" terminology with "authorization" and establishing new "adverse determination" definitions for denied services.

• Accelerates standard review timelines from 10 business days to 5 business days for electronic requests (effective immediately) and 5 business days regardless of submission method starting January 1, 2022; expedited reviews reduced from 72 hours to 48 hours.

• Prohibits prior authorization for emergency services and retroactive revocation of authorized services except in cases of fraud, misinformation, or legal conflicts; establishes 60-day continuity of care when enrollees change health plans.

• Requires health plan companies to post prior authorization requirements, restrictions, and denial data annually on public websites in understandable language; mandates 45-day notice before implementing new or changed prior authorization requirements.

• Creates new continuity of care protections by preventing mid-plan-year changes in clinical criteria from applying to previously authorized services and requiring submission of prior authorization criteria to all health plan companies.