H.F. No. 3268 Summary

• Utilization review organizations must submit annual prior authorization reports to the Commissioner of Commerce by September 1 each year, including data on requests, approvals, and denials broken down by service category (medical procedures, diagnostic tests, prescription medications, and other).

• Reports must include the number of adverse determinations appealed and whether they were upheld or reversed, plus reasons for denials such as patient not meeting criteria, incomplete information, treatment changes, or loss of coverage.

• Commissioner of Commerce must report to the legislature by February 15, 2024, on prior authorization practices including total requests, approvals without appeal, denials, and approvals after appeal.

• Commissioner must analyze submitted data and issue a comprehensive report on utilization management tools' effects on patient access, provider burden, and system costs, with recommendations for simplifying prior authorization processes and focusing review on overutilized services.

• If prior authorization approval rates for any service reach 80 percent or higher, the commissioner must recommend prohibiting prior authorization for that service effective August 1, 2024.