HB 2532 — prior authorization; uniform request form

HB2532 - 542R - H Ver       House Engrossed         State of Arizona House of Representatives Fifty-fourth Legislature Second Regular Session         HOUSE FLOORBILL AMENDMENT2532 EXPLANATION  Bill  Number:  AN ACT   amending sections 20‑3401 and 20‑3403, Arizona Revised Statutes;

HB2532amending Shahtitle Floor20, Amendmentchapter 1.26, article 1, Arizona Revised Statutes, by adding section 20‑3406;

Clarifiesrelating thatto DOI must approve the uniform prior authorization requestfor formcertain byhealth Januarycare 1,services. 2021.

2.    (TEXT OF BILL BEGINS ON NEXT PAGE)   Be it enacted by the Legislature of the State of Arizona:

ClarifiesSection 1.  Section that20-3401, DOIArizona mustRevised approveStatutes, a uniform prior authorization request form that is foramended prescriptionto drugs,read: devices or durable medical equipment and for all health care procedures, treatments and services.

3.START_STATUTE20-3401.  Definitions In this article, unless the context otherwise requires:

Mandates1.  "Adverse thatdetermination": all providers must only use the approved uniform prior authorization request form.

4.(a)  Means a decision by a health care services plan or its utilization review agent that the health care services furnished or proposed to be furnished to an enrollee are not medically necessary and plan coverage is therefore denied, reduced or terminated.

Requires(b)  Does thatnot allinclude priora authorizationdecision requeststo formsdeny, thatreduce areor submittedterminate afterservices Januarythat 1, 2022 are invalidnot unlesscovered thefor requestsreasons areother submittedthan onmedical thenecessity. approved uniform prior authorization request form.

5.2.  "Authorization":

Clarifies(a)  Means a determination by a health care services plan or its utilization review agent that thea two-pagehealth limitcare onservice approvedhas uniformbeen priorreviewed authorizationand, requestbased formson doesthe notinformation applyprovided, tosatisfies orthe includehealth acare provider'sservices notesplan's orrequirements documentationfor medical necessity and appropriateness and that payment under the providerplan submitswill inbe supportmade offor thethat priorhealth authorizationcare request.service.

6.(b)  Does not include any different or additional procedures, services or treatments beyond those specifically reviewed and approved by the health care services plan.

Includes3.  "Emergency anyambulance otherservices" formshas adopted by the directorsame ormeaning anotherprescribed state agency to the list of items that can be considered in thesection adoption20‑2801. of the approved uniform prior authorization request form.

7.4.  "Emergency services" has the same meaning prescribed in section 20‑2801.

Makes5.  "Enrollee" technicalmeans an individual or a dependent of that individual who is currently enrolled with and conformingcovered corrections.by a health care services plan.

AmendmentEnrollee explanationincludes preparedan byenrollee's Tracylegally Lopesauthorized Phonerepresentative. Number 602-926-5848 bf 2/20/2020 Fifty-fourth Legislature Shah Second Regular Session H.B.

25326.  "Health SHAHcare FLOORservice": AMENDMENT HOUSE OF REPRESENTATIVES AMENDMENTS TO H.B.

2532(a)  Means (Referencea tohealth printedcare bill)procedure, Pagetreatment 3,or lineservice 10,for strikethe "form"diagnosis, insertmanagement "FORMS"or Linetreatment 32,of strikeacute "form"pain, insertchronic "forms;pain or opioid use disorder that is covered under the health care services plan.

definition"(b)  Includes Linethe 33,provision strikeof "2022"providing inserta "2021"prescription Linedrug, 34,device strikeor "THAT"durable insertmedical "FORequipment PRESCRIPTIONfor DRUGS,the DEVICEStreatment ORor DURABLEmanagement MEDICALof EQUIPMENTacute ANDpain, Achronic UNIFORMpain PRIORor AUTHORIZATIONopioid REQUESTuse FORMdisorder FORthat ALLis OTHERcovered HEALTHunder CAREthe PROCEDURES,health TREATMENTScare ANDservices SERVICES.plan.

ON(c)  Does ORnot BEFOREinclude JANUARYtreatments 1,that 2022,are ALLexperimental, PROVIDERSinvestigational SHALLor USEoff ONLYlabel. THE APPROVED UNIFORM PRIOR AUTHORIZATION REQUEST FORMS AND ALL" Line 36, strike "FOR";

after7.  "Health "SUBMITTED"care strikeservices remainderplan": of line Line 37, strike "THAT ALL PROVIDERS ARE REQUIRED TO USE" insert "USING THE APPROVED UNIFORM PRIOR AUTHORIZATION REQUEST FORMS.

PRIOR(a)  Means AUTHORIZATIONa REQUESTSplan THAToffered AREby SUBMITTEDa ONdisability ORinsurer, AFTERgroup JANUARYdisability 1,insurer, 2022blanket AREdisability INVALIDinsurer, UNLESShealth THEcare REQUESTSservices AREorganization, SUBMITTEDhospital ONservice THEcorporation APPROVEDor UNIFORMmedical PRIORservice AUTHORIZATIONcorporation REQUESTthat FORMS"contractually Lineagrees 38,to strikepay "FORM"or insertmake "FORMS"reimbursements Linefor 39,health aftercare theservices secondexpenses periodfor insertone "THISor TWO-PAGEmore LIMITindividuals DOESresiding NOTin APPLYthis TOstate. OR INCLUDE A PROVIDER'S NOTES OR DOCUMENTATION THAT THE PROVIDER SUBMITS IN SUPPORT OF A PRIOR AUTHORIZATION REQUEST." Page 4, line 1, strike "FORM" insert "FORMS" Between lines 8 and 9, insert:

"(c)(b)  Does ANYnot OTHERinclude FORMbenefits ADOPTEDprovided BYunder THElimited DIRECTORbenefit ORcoverage ANOTHERas STATEdefined AGENCY."in Housesection Amendments20‑1137. to H.B.

25328.  "Medically Pagenecessary" 4,or after"medical linenecessity": 11, insert:

"C.(a)  Means covered health care services provided by a licensed provider acting within the provider's scope of practice in this state to prevent or treat disease, disability or other adverse conditions or their progression or to prolong life.

THIS(b)  Does SECTIONnot DOESinclude NOTservices PROHIBITthat Aare PAYORexperimental ORor ANYinvestigational ENTITYor ACTINGprescriptions FORthat Aare PAYORprescribed UNDERoff CONTRACTlabel. WITH THE PAYOR FROM USING A PRIOR AUTHORIZATION METHODOLOGY THAT USES AN INTERNET WEBPAGE, AN INTERNET WEBPAGE PORTAL OR A SIMILAR ELECTRONIC, INTERNET AND WEB-BASED SYSTEM IF THE METHODOLOGY IS CONSISTENT WITH THE UNIFORM PRIOR AUTHORIZATION REQUEST FORMS APPROVED BY THE DIRECTOR PURSUANT TO THIS SECTION.

D.9.  "Medication‑assisted treatment" has the same meaning prescribed in section 32‑3201.01.

FOR10.  "pharmacy THEbenefit PURPOSESmanager" OFhas THISthe SECTION,same "PROVIDER"meaning INCLUDESprescribed Ain HEALTHsection PROFESSIONAL20‑3321. AS DEFINED IN SECTION 32-3218 OR A HEALTH CARE INSTITUTION THAT IS LICENSED UNDER TITLE 36." Amend title to conform AMISH SHAH 2532FloorSHAH.docx 02/20/2020 8:32 AM C:

PP10.  11.  "Prior -2-authorization requirement":

(a)  Means a practice implemented by a health care services plan or its utilization review agent in which coverage of a health care service is dependent on an enrollee or a provider obtaining approval from the health care services plan before the service is performed, received or prescribed, as applicable.

(b)  Includes preadmission review, pretreatment review, prospective review or utilization review procedures conducted by a health care services plan or its utilization review agent before providing a health care service.

(c)  Does not include case management or step therapy protocols.

11.  12.  "Provider" means a physician, health care institution or other person or entity that is licensed or otherwise authorized to furnish health care services in this state.  12.  13.  "Urgent health care service" means a health care service with respect to which the application of the time periods for making a nonexpedited prior authorization decision, in the opinion of a provider with knowledge of the enrollee's medical condition, could either:

(a)  Seriously jeopardize the life or health of the enrollee or the ability of the enrollee to regain maximum function.

(b)  Subject the enrollee to severe pain that cannot be adequately managed without the care or treatment that is the subject of the utilization review.

13.  14.  "Utilization review agent" has the same meaning prescribed in section 20‑2501.

END_STATUTE Sec. 2.  Section 20-3403, Arizona Revised Statutes, is amended to read:

START_STATUTE20-3403.  Prior authorization requirements;

disclosures;

access A.  If a health care services plan contains a prior authorization requirement, all of the following apply: