Changes to Existing Law
HB1199 — Address prior authorization and reporting requirements by utilization review organizations and health carriers.
1 section modified+904-0
View:
§ 58-17
New Section+904
NEW SECTION added to Chapter 58-17
H: Before an adverse determination is issued, by a utilization review organization that 31 questions the medical necessity, appropriateness, or experimental or investigational 32 nature of a health care service, the organization shall provide to the health care 33 professional who ordered, requested, provided, or is to provide the service, a reasonable 34 opportunity to discuss the covered person's treatment plan and the clinical basis for the organization's determination with a health care professional employed by the organization. If the service was ordered, requested, provided, or is to be provided by a physician, the opportunity to discuss the treatment plan and the clinical basis must be with another physician who is licensed to practice medicine in this state and has the same or a similar specialty. This section applies only to a utilization review requested on or after July 1, 2026. 7