Section 420-E:4-b - [Effective 1/1/2025] Prior Authorization Standards For Managed Care PlansThe following prior authorization requirements apply to utilization review entities conducting prior authorization review determinations for managed care plans operating subject to RSA 420-J.
I. Timeliness standards for processing prior authorization requests submitted electronically. Utilization review entities administering fully insured coverage for managed care plans subject to RSA 420-J shall meet the following time frames for prior authorization determinations requested by participating providers or facilities that submit the prior authorization request through an electronic prior authorization process as designated by the utilization review entity:(a) In non-urgent circumstances, utilization review entities requiring prior authorization of a health care service shall approve or deny authorization and notify the covered person and the covered person's health care provider of the determination within 7 calendar days of obtaining all information necessary to make the determination. Any request that the utilization review entity makes for additional information necessary to make the determination shall be made within 7 calendar days of the prior authorization request date.(b) In urgent circumstances, utilization review entities requiring prior authorization of a health care service shall approve or deny authorization and notify the covered person and the covered person's health care provider of the determination as expeditiously as the covered person's medical condition requires, and not later than 72 hours after obtaining all information necessary to make the determination. Any request that the utilization review entity makes for additional information necessary to make the determination shall be made as expeditiously as required to meet the 72-hour timeline, assuming a timely response from the treating provider.II. Timeliness standards for processing prior authorization requests submitted non-electronically. Utilization review entities shall meet the following time frames for prior authorization determinations requested by participating providers or facilities that submit the prior authorization request through a non-electronic prior authorization process as designated by the utilization review entity:(a) In non-urgent circumstances, utilization review entities requiring prior authorization of a health care service shall approve or deny authorization and notify the covered person and the covered person's health care provider of the determination within 14 calendar days of obtaining all information necessary to make the determination. Any request that the utilization review entity makes for additional information necessary to make the determination shall be made within 7 calendar days of the prior authorization request date.(b) In urgent circumstances, utilization review entities requiring prior authorization of a health care service shall approve or deny authorization and notify the covered person and the covered person's health care provider of the determination as expeditiously as the covered person's medical condition requires, and not later than 72 hours after obtaining all information necessary to make the determination. Any request that the utilization review entity makes for additional information necessary to make the determination shall be made as expeditiously as required to meet the 72-hour timeline, assuming a timely response from the treating provider.III. In paragraphs I and II, "all information necessary to make the determination" shall include the information provided through a peer-to-peer review.IV. A prior authorization request shall be considered approved if the utilization review entity fails to notify the covered person and the covered person's health care provider of the prior authorization determination within the timeliness standards for making a determination after obtaining all necessary information.V. Duration of an approval of a prior authorization request. Utilization review entities shall not revoke, limit, condition, or restrict a prior authorization if care is provided within 60 business days from the date the health care provider received approval of the prior authorization request.VI. A utilization review entity conducting utilization review directly, or indirectly through a contracted utilization review entity, shall pay a participating health care provider at the contracted payment rate for a health care service provided by the health care provider pursuant to a prior authorization determination that coverage is available unless: (a) The health care provider materially misrepresented the health care service in the prior authorization request;(b) The health care service was no longer a covered benefit on the day it was provided;(c) The health care provider was no longer contracted with the covered person's utilization review entity on the date the care was provided;(d) The health care provider failed to meet the utilization review entity's timely filing requirements;(e) The patient was no longer eligible for health care coverage on the day the care was provided; or(f) The utilization review entity does not have liability for the claim or for a part of the claim for any reason under the covered person's coverage policy, the provider contract between the utilization review entity and the participating provider, or any other reason applicable at law or in equity.VII. Option to request a peer-to-peer review. When a utilization review entity requires prior authorization for an item or service, the utilization review entity shall offer the provider the opportunity to request a peer-to-peer review of a prior authorization request in which the provider is able to have a direct conversational exchange with a medical director or a designated provider who is a clinical peer about the basis for the prior authorization request. A "clinical peer" in this context shall be a health care professional who has demonstrable expertise to review a case, whether or not the reviewing professional is in the same or a similar specialty as the provider. The peer-to-peer review may be requested before the utilization review entity's prior authorization determination or after a prior authorization denial and before a formal grievance request has been made. The peer-to-peer review shall be made available by the utilization review entity within 2 business days of the request. If the peer-to-peer review is requested after a prior authorization denial, the utilization review entity shall treat the review request as a request for reconsideration that is external to the grievance process and shall provide the provider and the covered person a written determination containing a statement of the specific reasons for the reconsideration determination with reference to the information provided in the peer-to-peer review. The written reconsideration determination shall be provided within 7 business days of the peer-to-peer review.VIII. Nothing in this section shall be construed to contravene a covered person's right to external review under RSA 420-J:5-a. Unless otherwise required by law, the prior authorization requirements set out in this chapter shall apply to all medical services and items.Added by 2024, 172:11, eff. 1/1/2025.