HB 567 — Ensure Access to Biomarker Testing.

GENERAL ASSEMBLY OF NORTH CAROLINA SESSION 2025 H 21 HOUSE BILL 567 Committee Substitute Favorable 4/29/25 Short Title:

Representatives Wheatley, Penny, Campbell, and Moss (Primary Sponsors).

For a complete list of sponsors, refer to the North Carolina General Assembly web site.

Health, if favorable, Appropriations, if favorable, Rules, Calendar, and Operations of the House March 31, 2025 A BILL TO BE ENTITLED AN ACT TO ENSURE ACCESS TO AN EARLY AND ACCURATE DIAGNOSIS OF DEMENTIA IN ORDER TO IMPROVE ACCESS TO CARE AND SUPPORT SERVICES FOR, ENHANCE THE QUALITY OF LIFE OF, AND REDUCE THE FINANCIAL IMPACT OF THE CONDITION ON NORTH CAROLINIANS.

*H567-v-1* General Assembly Of North Carolina Session 2025 (8) Reserved for future codification purposes.

*H567-v-2* General Assembly Of North Carolina Session 2025 (9) Nationally recognized clinical practice guidelines.

Page 2 House Bill 567-First Edition General Assembly Of North Carolina Session 2025 SECTION 1.2.(a) G.S.

58-50-61 reads as rewritten:

"§ 58-50-61.

Utilization review.

(a) Definitions.

– As used in this section, in G.S.

58-50-62, and in Part 4 of this Article, the term:

… (16a) Urgent healthcare service.

– A healthcare service with respect to which the application of the time periods for making a non-expedited utilization review that,intheopinionofamedicaldoctorwithknowledgeofthecoveredperson's medical condition, could either (i) seriouslyjeopardize the life or health of the covered person or the ability of the covered person to regain maximum function or (ii) subject the covered person to severe pain that cannot be adequately managed without the care or treatment that is the subject of the utilization review.

The term urgent healthcare service includes mental and behavioral healthcare services.

… (f) Time Lines for Prospective and Concurrent Reviews.

Utilization Reviews Based Upon Type of Healthcare Service.

– As used in this subsection, the term "necessaryinformation" includes the results of any patient examination, clinical evaluation, or second opinion that may be required.

Prospective and concurrent determinations shall be communicated to The time line for completion of a prospective or concurrent utilization review is as follows:

(1) Non-urgent healthcare services.

– If an insurer requires a utilization review of a healthcare service, then the insurer or its URO shall both render a utilization review determination or noncertification and notifythe covered person and the covered person's provider within three business days after the insurer obtains all necessary information about the admission, procedure, or health care service.

to make the utilization review determination or noncertification.

(2) Urgent healthcare services.

– An insurer or its URO shall both render a utilization review determination or noncertification concerning urgent healthcare services and notify the covered person and the covered person's provider of that utilization review determination or noncertification not later than 24 hours after receiving all necessaryinformation needed to complete the review of the requested healthcare services.

If the covered person's provider or the insurer, or the entity conducting the review on behalf of the insurer, do not both have access to the electronic health records of the covered person, then this subdivision shall not apply and the utilization review will be subject to the time line under subdivision (1) of this subsection.

(f1) Utilization Review Determination Notifications.

– If an insurer or its URO certifies a health care healthcare service, the insurer shall notify notification shall be sent to the covered person's provider.

For If an insurer or its URO issues a noncertification, the insurer shall notify the covered person's provider and send then written or electronic confirmation of the noncertification shall be sent to the covered person's provider and covered person.

In person that is in compliance with subsection (h) of this section.

(f2) Concurrent Review Liability.

– For concurrent reviews,the insurer shall remainliable for health care healthcare services until the covered person has been notified of the noncertification.

… (m) Disclosure of Utilization Review Requirements.

– Information required to be provided under this section shall be described in detail and in easily understandable language.

All of the following apply to an insurer's responsibility to disclose any utilization review procedures:

House Bill 567-First Edition Page 3 General Assembly Of North Carolina Session 2025 (1) Coverage and member handbook.

– In the certificate of coverage and member handbook provided to covered persons, an insurer shall include a clear and comprehensive description of its utilization review procedures, including the procedures for appealing noncertifications and a statement of the rights and responsibilities of covered persons, including the voluntary nature of the appeal process, with respect to those procedures.

An insurer shall also include in the certificate of coverage and the member handbook information about the availability of assistance from the Department's Health Insurance Smart NC, including the telephone number and address of the Program.

program.

(2) Prospective materials.