NOTICES
INSURANCE DEPARTMENT
Act 146 of 2022—Implementation of Prior Authorization Provisions; Notice 2024-11
[54 Pa.B. 4407]
[Saturday, July 27, 2024]The act of November 3, 2022 (Pub.L. 2068, No. 146) (Act 146) amended the act of May 17, 1921 (Pub.L. 682, No. 284) by, inter alia, substantially increasing the Insurance Department's (Department) oversight related to the Commonwealth's commercial health insurance prior authorization requirements and appeal processes. Section 2155 of Act 146 specifically addresses prior authorization review and peer-to-peer reviews. The Department reminds insurers of the requirements of, and its expectations for compliance with, these provisions.
List of health care services requiring prior authorization. Section 2155(b) of Act 146 (40 P.S. § 991.2155(b)) requires each insurer to publicly post a list indicating the health care services for which the insurer requires prior authorization. That list must be in a publicly accessible format and location on the insurer's web site. The Department expects that consumers and providers, as well as the Department and other interested parties, will be able to easily access, navigate and rely on the accuracy of each insurer's list.
Qualifications of health care providers denying prior authorization requests. Section 2155(d) of Act 146 (40 P.S. § 991.2155(d)) prohibits an insurer from denying, other than an administrative denial, a prior authorization request unless the insurer's representative reviewing the prior authorization request is a licensed health care provider ''with appropriate training, knowledge or experience in the same or similar specialty that typically manages or consults on the health care service in question.'' (Emphasis added.) Alternatively, the reviewing licensed health care provider may consult with another licensed health care provider that meets the same criteria.
Qualifications of peer-to-peer reviewers reviewing prior authorization requests. Section 2155(e) of Act 146 (40 P.S. § 991.2155(e)) requires that an insurer's peer-to-peer reviewer also meet the section 2155(d) criteria, that is, that the peer-to-peer reviewer be a licensed health care provider ''with appropriate training, knowledge or experience in the same or similar specialty that typically manages or consults on the health care service in question.'' (Emphasis added.) The Department expects that insurers will be able to demonstrate that the reviewer, or the physician with which the reviewer is consulting, is of the ''same or similar specialty'' in situations addressed by either section 2155(d) or (e).
Insurers are reminded of the Department's jurisdiction to investigate potential violations and the Department's ability to enforce the provisions of Act 146, including these and the other requirements in section 2155. See 40 P.S. §§ 991.2181(d) and 991.2182. The Department encourages insurers to ensure their compliance with these requirements, which have been put into place to streamline coverage and claims determinations.
Questions regarding this notice may be directed to the Bureau of Market Regulation, Insurance Department, 1326 Strawberry Square, Harrisburg, PA 17120, ra-in-markregulation@pa.gov.
MICHAEL HUMPHREYS,
Insurance Commissioner
[Pa.B. Doc. No. 24-1063. Filed for public inspection July 26, 2024, 9:00 a.m.]
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