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ARIZONA STATE SENATE
Fifty-Fourth Legislature, Second Regular Session
prior authorization; uniform request form
Purpose
Directs the Department of Insurance (DOI) to approve uniform prior authorization request forms by January 1, 2021 and prescribes uniform prior authorization request form criteria. Requires health care providers to utilize the DOI-approved prior authorization request forms by January 1, 2022.
Background
A prior authorization requirement is a practice implemented by a health care services plan, or its utilization review agent, in which coverage of a health care service is dependent upon approval from the plan before the service is performed, received or prescribed. Prior authorization requirements can include preadmission, pretreatment, prospective and utilization review procedures. Prior authorization requirements do not apply to case management or step therapy protocols. Health care services that may be subject to a health care services plan's prior authorization requirements include procedures, treatments and services for diagnosing, managing or treating acute pain, chronic pain or opioid use disorder as well as any associated prescription drugs, devices and medical equipment (A.R.S. § 20-3401).
There is no anticipated fiscal impact to the state General Fund associated with this legislation.
Provisions
1. Directs DOI, by January 1, 2021, to approve separate uniform prior authorization request forms for:
a) prescription drugs, devices and durable medical equipment; and
b) all other health care procedures, treatments and services.
2. Stipulates that uniform prior authorization request forms must:
a) not exceed two printed pages, excluding provider's notes or other documentation submitted by a provider in support of a prior authorization request; and
b) meet prescribed electronic submission and acceptance requirements.
3. Requires DOI to do the following when approving uniform prior authorization request forms:
a) consider any existing prior authorization request forms developed by the Centers for Medicare and Medicaid Services or the U.S. Department of Health and Human Services;
b) consider any other form adopted by the DOI Director or another Arizona agency; and
c) seek input from stakeholders, providers, health care services plans, utilization review agents, pharmacists and pharmacy benefits managers.
4. Obligates health care providers, by January 1, 2022, to only use the DOI-approved prior authorization request forms.
5. Obligates health care services plans and utilization review agents to accept and process prior authorization request forms submitted using the DOI-approved forms by January 1, 2022.
6. Invalidates prior authorization requests submitted on or after January 1, 2022, unless the request was submitted on a DOI-approved form.
7. Asserts that uniform prior authorization request form requirements do not preclude a payor, or any contracted entity acting for a payor, from using a prior authorization methodology that includes an internet webpage, webpage portal or similar electronic internet-based system if the methodology is consistent with the DOI-approved forms.
8. Modifies the definition of health care service.
9. Defines pharmacy benefit manager and provider.
10. Makes technical and conforming changes.
11. Becomes effective on the general effective date.
House Action
HHS 1/30/20 DP 9-0-0-0
3rd Read 2/27/20 60-0-0
Prepared by Senate Research
March 9, 2020
CRS/kja