Subjects certain entities to insurance code uniform medical claim, billing forms rules.
Entities include fraternal benefit societies, dental service plan corporations, health maintenance orgs, limited health service orgs, and health services plan corporations.
Amends definitions of adverse determination and final adverse determination.
Revises provisions were a health care plan or other utilization review program uses an algorithmic automated process in the course of utilization review for medical necessity.
In such cases, plan/review program shall ensure that only a clinical peer makes any adverse determination based on medical necessity, a subsequent appeal is processed.
Also, adds the National Committee for Quality Assurance to a provision requiring utilization review programs to certify compliance with certain accreditation entities.
Legislative History
On Feb. 15, 2023, bill introduced in House; on Apr. 19, 2024, bill passed as amended.
on Apr. 24, 2024, bill introduced in Senate; on May 15, 2024, bill passed in Senate.
Effectiveness
Once enacted, bill provisions take effect on Jan. 1, 2025.
