ARIZONA HOUSE OF REPRESENTATIVES Fifty-seventh Legislature First Regular Session

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HB 2175: claims; prior authorization; conduct

Sponsor: Representative Willoughby, LD 13

Committee on Commerce

Overview

Requires a health care provider to review each claim for health care services before denial or prior authorization.

History

A health care services plan or its utilization review agent may impose a prior authorization requirement for health care services provided to an enrollee.  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 on an enrollee or a provider obtaining approval from the health care services plan before the service is performed, received or prescribed, as applicable. If the prior authorization request is denied, the health care services plan or its utilization review agent shall state the specific reason for the denial. On a denial of a prior authorization request, the enrollee and the provider may exercise the review and appeal rights granted under the health care appeals process (A.R.S. §§ 20-3402, 20-3404).

A member who receives an adverse determination may pursue the applicable review process as prescribed in statute.  A health care insurer must provide at least the following levels of review: 1) an expedited medical review and expedited appeal; 2) an initial appeal; and 3) an external independent review (A.R.S. § 20-2533).

Provisions

1. Requires a health care provider to individually review each claim for health care services before a health care insurer denies a claim or a prior authorization unless:

a) the denial is due to a lack of administrative completeness;

b) the member enrollment status is excluded from coverage under the plan; or

c) a determination is made that a service or provider type is categorically excluded from coverage under the plan. (Sec. 1)

2. Prohibits the use of artificial intelligence to deny a claim or prior authorization. (Sec. 1)

3. Classifies the denial of a claim or a prior authorization without an individual review of the claim as an act of unprofessional conduct. (Sec. 1)

4. Outlines the health care professionals that are defined as a health care provider. (Sec. 1)

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8.                   HB 2175

9. Initials PB           Page 0 Commerce

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