HB 3010 — Creates provisions relating to prior authorization of health care services

Bill Text

Compared against the Missouri Revised Statutes as published AI-generated reading aid — verify against the official bill.

This bill amends 8 section(s) of the Missouri Revised Statutes: Section 376.1363, RSMo; Section 376.1364, RSMo; Section 376.1366, RSMo; Section 376.2100, RSMo; Section 376.2102, RSMo; Section 376.2104, RSMo.

• Section 376.1363, RSMo

  forty-five working days of the date the health care provider receives the prior authorization → bold-face (1) the lesser of six months after the date the health care provider receives the prior authorization approval or the length of treatment as determined by the patient's health care provider (2) Ifalth carrier requires a prior authorization for a recurring health care service or maintenance medication for the treatment of a chronic or long-term condition as defined by the United States Centers for Disease Control and Prevention, including, but not limited to, chemotherapy for the treatment of cancer, the approval shall remain valid for the lesser of twelve months from the date the health care professional or health care provider receives the prior authorization approval or the length of the treatment as determined by the patient's health care provider. A health carrier and an enrollee or his or her health care provider may extend a prior authorization approval for a longer period by mutual agreement. 9. The failure of a health carrier to comply with the deadlines and requirements of this section shall result in any health care services subject to prior authorization to be automatically deemed authorized by the health carrier for a duration of time of at least the time frames set forth in subsection 7 of this section.

  amended

• Section 376.1364, RSMo

  and timestamp For plan years beginning on or after January 1, 2027, a health carrier or its utilization review entity shall implement and maintain a prior authorization application programming interface (API) that conforms with 45 CFR 156.221(c)(2) through (4), (d), and (e) and the standards in 45 CFR 170.215(a)(1), (b)(1)(i), and (c)(1) to respond to requests for prior authorization for health care services, excluding prescription drugs. If a health carrier cannot implement the prior authorization API by January 1, 2027, the health carrier shall provide written notice to the department requesting an extension, accompanied by a documented plan to come into compliance. 5. An enrollee's health care provider shall use the prior authorization API, as described in subsection 4 of this section, to submit requests for prior authorization for health care services, excluding prescription drugs. 6. For contracts between health carriers and participating health care providers entered into or renewed on or after January 1, 2027, a health carrier shall include a provision that requires health care providers to submit prior authorization requests using the application programming interface described in subsection 4 of this section. If a participating health care provider fails to utilize the prior authorization API to submit requests, the enrollee shall not be subject to cost sharing in excess of the in-network cost-sharing amount. 7. For plan years beginning on or after January 1, 2027, a health carrier using prior authorization shall make statistics available regarding prior authorization approvals and denials for health care services, excluding drugs, on its website in a readily accessible format. Health carriers shall submit the uniform resource locator (URL) for the website location where such statistics are posted to the department, and the department shall publish the website locations in a central location on the department's website. The statistics shall be updated each year thereafter, no later than March thirty-first, and shall include all the following information: (1) The percentage of standard prior authorization requests that were approved, aggregated for all health care services; (2) Thercentage of standard prior authorization requests that were denied, aggregated for all health care services; (3) Thercentage of prior authorization requests that were approved after appeal, aggregated for all health care services; (4) The percentage of prior authorization requests for which the time frame for review was extended, and the request was approved, aggregated for all health care services; (The percentage of expedited prior authorization requests that were approved, aggregated for all health care services; (6) The percentage of expedited prior authorization requests that were denied, aggregated for all health care services; (7) The average and median time that elapsed between the submission of a request and a determination by the health carrier for standard prior authorization, aggregated for all health care services; (8) Theverage and median time that elapsed between the submission of a request and a decision by the health carrier for expedited prior authorizations, aggregated for all health care services; and (9) Any other information as the department determines appropriate. managed care component shall report annually to the department, in a manner specified by the department, a complete list of the health care services, excluding drugs, for which prior authorization is required, including for services where prior authorization is performed by the health carrier's utilization review entity. Health carriers shall reduce the scope of claims subject to prior authorizations. To promote consistency among carriers, the department shall review the reports submitted under subsection 8 of this section and compile an annual report to be published on the department's website no later than October first of each year. 10. No later than May 3

  amended

• Section 376.1366, RSMo

  include a provision for the continuation of prior authorization approvals for enrollees from a previous health carrier for at least one hundred eighty days from the effective date of the enrollee's coverage under the new health benefit plan, subject to the terms of the certificate of coverage. 2At any time during the one-hundred-eighty-day period described in subsection 1 of this section, the new health carrier may perform its own review to grant a prior authorization approval subject to the terms of the certificate of coverage. 3. If there is a change in coverage of, or approval criteria for, a previously authorized health care service, the change in coverage or approval criteria shall not affect an enrollee who received prior authorization approval before the effective date of the change through the remainder of the enrollee's plan year. 4. Except to the extent required by medical exceptions processes for prescription drugs, nothing in this section shall require a health benefit plan to cover any care, treatment, or services for any health condition that the certificate of coverage otherwise completely excludes from the health benefit plan's covered benefits without regard for

  amended

• Section 376.2100, RSMo

  used in sections 376.2100 to 376.2108, terms shall have the same meanings as are ascribed to them under section 376.1350. 2. As used in sections 376.2100 to 376.2108, the term "evaluation period" means

  amended

• Section 376.2102, RSMo

  2027, a health carrier or utilization review entity shall not require a health care provider to obtain prior authorization for a health care service unless the health carrier or utilization review entity makes a determination that in the most recent evaluation period the health carrier or utilization review entity has approved or would have approved less than ninety percent of the prior authorization requests submitted by that provider for that health care service. 2.inning January 1, 2027, a health carrier or utilization review entity shall not require a health care provider to obtain prior authorization for any health care services unless the health carrier or utilization review entity makes a determination that in the most recent evaluation period the health carrier or utilization review entity has approved or would have approved less than ninety percent of all prior authorization requests submitted by that provider for health care services. 3. In making a determination under this section, the health carrier or utilization review entity shall not count: (1) Any prior authorization requests denied by a health carrier or utilization review entity and being appealed by the health care provider; or (2) Any request made by a health care provider for a service that is not included in the health carrier's benefit plan but shall count as approved any prior authorization request that was denied by a health carrier or utilization review entity but that was subsequently authorized. 4. In making a determination under this section, the health carrier or utilization review entity shall use either the provider's National Provider Identifier or a taxpayer identification number. Such designation shall remain unless requested to be changed by the provider. 5The exemption from prior authorization requirements described in subsections 1 and 2 of this section may be subject to internal auditing of the most recent consecutive six months, up to a maximum of two times per year, by the health carrier or utilization review entity and may be rescinded if: (1) Such carrier or utilization review entity determines that the carrier or utilization review entity would have approved less than ninety percent of prior authorization requests for a health care service for which the provider was exempt from the prior authorization requirement under subsection 1 of this section; or (2) Such carrier or utilization review entity determines that the carrier or utilization review entity would have approved less than ninety percent of all prior authorization requests if the provider was exempt from the prior authorization requirement under subsection 2 of this section. 6. exemption described in subsections 1 and 2 of this section shall be null and void upon a determination that the health care provider has been found by a court of law to have civilly or criminally engaged in any fraud or abuse after the exemption is granted by a health carrier or utilization review entity. 7. A health carrier or utilization review entity may require health care providers in the health carrier's or utilization review entity's network to use an online portal to submit requests for prior authorization. 8. No adverse determination shall be finalized under subsection 1, 2, or 5 of this

  amended

• Section 376.2104, RSMo

  care provider no later than twenty-five days after any determination made under

  amended

• Section 376.2102, RSMo

  documentation for making the determination for the relevant evaluation period. 2. The health carrier or utilization review entity shall establish a process for health care providers to appeal any determinations made under section 376.2102. 3. The health carrier or utilization review entity shall maintain an online portal to allow health care providers to access all prior authorization decisions, including

  amended

• Section 376.2102, RSMo

  authorizations, the portal shall include the status of each prior authorization request, all notifications to the health care provider, the dates the health care provider received such

  amended

• Section 376.2106, RSMo

  payment to a health care provider for a health care service for which the provider has a prior authorization unless the provider: (1) Knowingly and materially misrepresented the health care service in a request for payment submitted to the health carrier or utilization review entity with the specific intent to deceive and obtain an unlawful payment from the carrier or entity; or

  amended

• Section 376.2108, RSMo

  MO HealthNet, except that a Medicaid managed care organization as defined in section 208.431 shall be considered a health carrier for purposes of sections 376.2100 to 376.2108. 2. The provisions of sections 376.2100 to 376.2108 shall not apply to health care providers who have not participated in a health benefit plan offered by the health carrier for at least one full evaluation period. 3. Nothing in sections 376.2100 to 376.2108 shall be construed to: (1)horize a health care provider to provide a health care service outside the scope of his or her applicable license; or (2) Require a health carrier or utilization review entity to pay for a health care service described in subdivision (1) of this subsection.

  amended

• Amendment 6673H02.02H (Distributed) Show changes
• Amendment 6673H02.03H (Distributed) Show changes

Action History

1. April 21, 2026

   Public Hearing Held (S)

2. April 16, 2026

   Public Hearing Scheduled (S) - Tuesday, April 21, 2026, 12:00 p.m., Senate Lounge - 3rd Floor

3. March 31, 2026

   Second read and referred: Insurance and Banking(S)

4. March 19, 2026

   Reported to the Senate and First Read (S)

5. March 16, 2026

   Delivered to the Senate

6. March 12, 2026

   Third Read and Passed (H) - AYES: 143 NOES: 1 PRESENT: 0

7. March 12, 2026

   Taken Up for Third Reading (H)

8. March 12, 2026

   Placed on the Informal Third Reading Calendar (H)

9. March 12, 2026

   Reported Do Pass (H) - AYES: 7 NOES: 0 PRESENT: 1

10. March 12, 2026

    Voted Do Pass (H)

11. March 12, 2026

    Executive Session Completed (H)

12. March 11, 2026

    Referred: Fiscal Review(H)

13. March 10, 2026

    Perfected (H)

14. March 10, 2026

    HCS Adopted (H)

15. March 10, 2026

    Title of Bill - Agreed To

16. March 10, 2026

    Taken Up for Perfection (H)

17. March 10, 2026

    Placed on the Informal Perfection Calendar (H)

18. March 05, 2026

    Reported Do Pass (H) - AYES: 10 NOES: 0 PRESENT: 1

19. March 04, 2026

    Voted Do Pass (H)

20. March 04, 2026

    Executive Session Completed (H)

21. March 02, 2026

    Referred: Rules - Administrative(H)

22. February 26, 2026

    HCS Reported Do Pass (H) - AYES: 10 NOES: 0 PRESENT: 0

23. February 26, 2026

    HCS Voted Do Pass (H)

24. February 26, 2026

    Executive Session Completed (H)

25. February 19, 2026

    Public Hearing Completed (H)

26. February 17, 2026

    Referred: Health and Mental Health(H)

27. January 21, 2026

    Read Second Time (H)

28. January 20, 2026

    Introduced and Read First Time (H)

Sponsors

• Jamie Ray Gragg · Cosponsor
• Carolyn Caton · Cosponsor
• George Hruza · Cosponsor
• Ron Fowler · Cosponsor
• Jeremy Dean · Cosponsor
• Melanie Stinnett · Primary

Votes

Subjects