Prior authorization - Urgent healthcare service

(a) A utilization review entity shall render an expedited authorization or adverse determination concerning an urgent healthcare service and notify the subscriber and the subscriber's healthcare provider of that expedited prior authorization or adverse determination no later than one (1) business day after receiving all information needed to complete the review of the requested urgent healthcare service. (b) (1) If a utilization review entity denies a prior authorization of an urgent healthcare service, then the subscriber or the healthcare provider may elect to appeal the denial of the prior authorization of the urgent healthcare service. (2) If a denial of a prior authorization of an urgent healthcare service is appealed to the utilization review entity, then within two (2) business days of receiving all necessary information required, the utilization review entity shall: (A) Make an authorization or adverse determination; and (B) Notify the subscriber and the healthcare provider that appealed the denial of the prior authorization of the urgent healthcare service of the decision. (3) This subsection applies to an enrollee who is being evaluated or treated for: (A) A hematology diagnosis; (B) An oncology diagnosis; or (C) An additional disease state or other diagnoses that the Insurance Commissioner may include by rule. Amended by Act 2023, No. 501,§ 3, eff. 8/1/2023. Added by Act 2015, No. 1106,§ 2, eff. 7/22/2015.

(a) A utilization review entity shall render an expedited authorization or adverse determination concerning an urgent healthcare service and notify the subscriber and the subscriber's healthcare provider of that expedited prior authorization or adverse determination no later than one (1) business day after receiving all information needed to complete the review of the requested urgent healthcare service.

(b) (1) If a utilization review entity denies a prior authorization of an urgent healthcare service, then the subscriber or the healthcare provider may elect to appeal the denial of the prior authorization of the urgent healthcare service. (2) If a denial of a prior authorization of an urgent healthcare service is appealed to the utilization review entity, then within two (2) business days of receiving all necessary information required, the utilization review entity shall: (A) Make an authorization or adverse determination; and (B) Notify the subscriber and the healthcare provider that appealed the denial of the prior authorization of the urgent healthcare service of the decision. (3) This subsection applies to an enrollee who is being evaluated or treated for: (A) A hematology diagnosis; (B) An oncology diagnosis; or (C) An additional disease state or other diagnoses that the Insurance Commissioner may include by rule.

(1) If a utilization review entity denies a prior authorization of an urgent healthcare service, then the subscriber or the healthcare provider may elect to appeal the denial of the prior authorization of the urgent healthcare service.

(2) If a denial of a prior authorization of an urgent healthcare service is appealed to the utilization review entity, then within two (2) business days of receiving all necessary information required, the utilization review entity shall: (A) Make an authorization or adverse determination; and (B) Notify the subscriber and the healthcare provider that appealed the denial of the prior authorization of the urgent healthcare service of the decision.

(A) Make an authorization or adverse determination; and

(B) Notify the subscriber and the healthcare provider that appealed the denial of the prior authorization of the urgent healthcare service of the decision.

or adverse determination; and (B) Notify the subscriber and the healthcare provider that appealed the denial of the prior authorization of the urgent healthcare service of the decision.

(A) Make an authorization or adverse determination; and

(B) Notify the subscriber and the healthcare provider that appealed the denial of the prior authorization of the urgent healthcare service of the decision.

(3) This subsection applies to an enrollee who is being evaluated or treated for: (A) A hematology diagnosis; (B) An oncology diagnosis; or (C) An additional disease state or other diagnoses that the Insurance Commissioner may include by rule.

(A) A hematology diagnosis;

(B) An oncology diagnosis; or

(C) An additional disease state or other diagnoses that the Insurance Commissioner may include by rule.

Amended by Act 2023, No. 501,§ 3, eff. 8/1/2023.

Added by Act 2015, No. 1106,§ 2, eff. 7/22/2015.