Legislation to simplify the prior authorization process went into effect January 2017.
- Insurers must disclose all prior authorization rules to participating providers, including specific information or documentation that a physician or other health care professional must submit in order for the prior authorization request to be considered complete.
- Insurers must disclose to all participating physicians or other health care professionals all new prior authorization requirements at least 30 days prior to the effective date of the new requirement.
- Enrollees of the health plan must receive basic information about which drugs and services will require prior authorization.
- A provision prohibiting retroactive denials when, on the date the physician or other health care professional renders the prior approved service:
- The patient is eligible
- The patient’s condition hasn’t changed
- The physician submits an accurate claim that matches the information submitted by the physician in the approved prior authorization request.
- A provision allowing a retrospective review of a claim where a prior authorization was required but not obtained when the service in question meets all of the following:
- The service is related to another service for which a prior authorization has already been obtained and has already been performed
- The service was not known to be needed at the time the original prior authorized service was performed
- The need for the new service was revealed at the time the original authorized service was performed.
- Insurers must allow for a 12-month prior authorization for medications to treat a chronic disease under certain circumstances.
The Ohio Academy of Family Physicians is working with the Ohio State Medical Association to monitor compliance with these new requirements. If practices have any issues with insurers complying with the prior authorization regulations that went into effect on January 1, 2017, please submit a complaint to the Ohio Department of Insurance by completing the online form.
Additional prior authorization requirements for insurers go into effect in January 2018 including that insurers must have a web-based system through which to receive prior authorization requests; faster turnaround times for prior authorizations will be mandatory; insurers will be required to respond to prior authorization requests with more clarity; and faster turnaround times for prior authorization appeals will be mandatory.