Healthcare

Health insurance; prior authorization for health care services. Decreases from 72 hours to 24 hours and from seven days to five days the time by which a health insurance carrier is required to respond to expedited and standard requests for prior authorization for health care services, respectively. The bill prohibits a carrier from (i) denying a claim for the provision of dental services by a dentist or oral surgeon for failure to obtain prior authorization if the dentist or oral surgeon calls the dental plan during business hours to obtain such prior authorization and is unable to reach the dental plan or is placed on hold for longer than 15 minutes and (ii) downcoding a claim if a prior authorization was approved. The bill requires carriers to establish a system in which providers with high prior authorization approval rates are not required to obtain prior authorization for routine health care services. Additionally, the bill provides that if a prior authorization request is denied, the carrier is required to notify providers and enrollees if artificial-intelligence based tools were used in reviewing the request.