reglab/statecodes huggingface dataset:
Arkansas Code of 1987 (2023) › Title 23 - PUBLIC UTILITIES AND REGULATED INDUSTRIES (§§ 23-1-101 — 23-119-105) › Subtitle 3 - INSURANCE (§§ 23-60-101 — 23-103-417) › Chapter 99 - HEALTH CARE PROVIDERS (§§ 23-99-201 — 23-99-1802) › Subchapter 9 - LIMITATION ON FINANCIAL PENALTIES IN ALTERNATIVE PAYMENT SYSTEMS (§§ 23-99-901 — 23-99-905) › Section 23-99-901 - Legislative findings

The General Assembly finds that:
(1)
Under an alternative payment system, a healthcare payor, when determining a healthcare provider's patient care costs, may use factors that are not under the control of the healthcare provider;
(2)
A healthcare provider may not receive an appropriate share of savings or reduction in recoupment under an alternative payment system if the healthcare provider's patients have a higher cost of care; and
(3)
A healthcare provider should not be penalized for higher patient care costs if any of the costs, or other factors determining reimbursement, are not under the control of the healthcare provider.
Amended by Act 2019, No. 862,§ 1, eff. 7/24/2019.
Added by Act 2015, No. 902,§ 1, eff. 7/22/2015.
Arkansas Code of 1987 (2023) › Title 23 - PUBLIC UTILITIES AND REGULATED INDUSTRIES (§§ 23-1-101 — 23-119-105) › Subtitle 3 - INSURANCE (§§ 23-60-101 — 23-103-417) › Chapter 99 - HEALTH CARE PROVIDERS (§§ 23-99-201 — 23-99-1802) › Subchapter 9 - LIMITATION ON FINANCIAL PENALTIES IN ALTERNATIVE PAYMENT SYSTEMS (§§ 23-99-901 — 23-99-905) › Section 23-99-902 - Definitions

As used in this subchapter:
(1)
"Alternative payment system" means a payment methodology used by a healthcare payor that includes a risk-sharing or gain-sharing component for a healthcare provider that participates in a plan, program, or network offered by the healthcare payor;
(2)
"Gain-sharing payment" means an increase in a payment or additional payments made by a healthcare payor to a healthcare provider as a result of the achievement of identified benchmarks, including without limitation that patient care costs fall below cost thresholds of any form;
(3)
(A)
"Healthcare payor" means an entity that reimburses a physician for the delivery of healthcare services that are covered by a plan administered, issued, or delivered by the entity.
(B)
"Healthcare payor" does not include a provider-based network or system that utilizes risk-sharing including an accountable care organization or a clinically integrated network;
(4)
"Healthcare provider" means any type of provider that renders healthcare services to patients for compensation, including:
(A)
A doctor of medicine, a doctor of osteopathy, or another licensed healthcare professional acting within the professional's licensed scope of practice; or
(B)
A healthcare facility, including a hospital, ambulatory surgery center, or other type of facility licensed in this state to provide healthcare services; and
(5)
(A)
"Risk-sharing payment" means a reduction in a payment to or refund of a payment already made to a healthcare provider as a result of failure to achieve identified benchmarks, including without limitation that patient care costs exceed cost thresholds of any form.
(B)
"Risk-sharing payment" includes the alternative payment method by gift card, credit card, or other type of electronic payment or virtual credit card as payment if the healthcare provider is given clear instructions about how to select an alternative payment method that does not result in the healthcare provider's being charged a service fee to process.
Amended by Act 2019, No. 862,§ 1, eff. 7/24/2019.
Amended by Act 2019, No. 300,§ 3, eff. 7/24/2019.
Amended by Act 2017, No. 724,§ 1, eff. 8/1/2017.
Added by Act 2015, No. 902,§ 1, eff. 7/22/2015.
Arkansas Code of 1987 (2023) › Title 23 - PUBLIC UTILITIES AND REGULATED INDUSTRIES (§§ 23-1-101 — 23-119-105) › Subtitle 3 - INSURANCE (§§ 23-60-101 — 23-103-417) › Chapter 99 - HEALTH CARE PROVIDERS (§§ 23-99-201 — 23-99-1802) › Subchapter 9 - LIMITATION ON FINANCIAL PENALTIES IN ALTERNATIVE PAYMENT SYSTEMS (§§ 23-99-901 — 23-99-905) › Section 23-99-903 - Physician penalties - Limitation

(a)
A healthcare payor doing business in this state, when determining any gain-sharing or risk-sharing for a healthcare provider, shall not attribute to a healthcare provider any costs that are a result of variations in the healthcare payor's freely negotiated contract pricing with other persons or entities outside the healthcare provider's practice if including the costs reduces a healthcare provider's gain-sharing amount or increases a healthcare provider's risk-sharing amount.
(b)
(1)
When determining any gain-sharing or risk-sharing for a healthcare provider based on the achievement of or failure to attain certain benchmarks, a healthcare payor doing business in this state shall use clearly expressed and identifiable benchmarks.
(2)
At least ninety (90) days in advance of implementation, the healthcare payor shall explain to the healthcare provider the applicability of the identifiable benchmarks.
(3)
Any identifiable benchmarks shall be within the control of the healthcare provider to achieve or fail to attain.
Amended by Act 2019, No. 862,§ 1, eff. 7/24/2019.
Added by Act 2015, No. 902,§ 1, eff. 7/22/2015.
Arkansas Code of 1987 (2023) › Title 23 - PUBLIC UTILITIES AND REGULATED INDUSTRIES (§§ 23-1-101 — 23-119-105) › Subtitle 3 - INSURANCE (§§ 23-60-101 — 23-103-417) › Chapter 99 - HEALTH CARE PROVIDERS (§§ 23-99-201 — 23-99-1802) › Subchapter 9 - LIMITATION ON FINANCIAL PENALTIES IN ALTERNATIVE PAYMENT SYSTEMS (§§ 23-99-901 — 23-99-905) › Section 23-99-904 - Waiver prohibited

(a)
The provisions of this subchapter shall not be waived by contract.
(b)
Contractual arrangements or actions taken in conflict with this subchapter or that purport to waive any requirements of this subchapter are void.
Amended by Act 2019, No. 862,§ 1, eff. 7/24/2019.
Added by Act 2017, No. 724,§ 2, eff. 8/1/2017.
Arkansas Code of 1987 (2023) › Title 23 - PUBLIC UTILITIES AND REGULATED INDUSTRIES (§§ 23-1-101 — 23-119-105) › Subtitle 3 - INSURANCE (§§ 23-60-101 — 23-103-417) › Chapter 99 - HEALTH CARE PROVIDERS (§§ 23-99-201 — 23-99-1802) › Subchapter 9 - LIMITATION ON FINANCIAL PENALTIES IN ALTERNATIVE PAYMENT SYSTEMS (§§ 23-99-901 — 23-99-905) › Section 23-99-905 - Enforcement

(a)
The State Insurance Department shall develop and promulgate rules for the implementation and enforcement of this subchapter.
(b)
In addition to or as an alternative to any enforcement action by the department, a healthcare provider or an organization that represents healthcare providers may enforce this subchapter by filing suit against a healthcare payor in:
(1)
Pulaski County Circuit Court; or
(2)
The circuit court of a county in Arkansas in which one (1) of the healthcare provider claimants resides or does business.
Amended by Act 2019, No. 862,§ 1, eff. 7/24/2019.
Added by Act 2017, No. 724,§ 2, eff. 8/1/2017.
Arkansas Code of 1987 (2023) › Title 23 - PUBLIC UTILITIES AND REGULATED INDUSTRIES (§§ 23-1-101 — 23-119-105) › Subtitle 3 - INSURANCE (§§ 23-60-101 — 23-103-417) › Chapter 99 - HEALTH CARE PROVIDERS (§§ 23-99-201 — 23-99-1802) › Subchapter 10 - VISION CARE PLAN ACT OF 2015 (§§ 23-99-1001 — 23-99-1005) › Section 23-99-1001 - Title

This subchapter shall be known and may be cited as the "Vision Care Plan Act of 2015".
Added by Act 2015, No. 959,§ 1, eff. 7/22/2015.
Arkansas Code of 1987 (2023) › Title 23 - PUBLIC UTILITIES AND REGULATED INDUSTRIES (§§ 23-1-101 — 23-119-105) › Subtitle 3 - INSURANCE (§§ 23-60-101 — 23-103-417) › Chapter 99 - HEALTH CARE PROVIDERS (§§ 23-99-201 — 23-99-1802) › Subchapter 10 - VISION CARE PLAN ACT OF 2015 (§§ 23-99-1001 — 23-99-1005) › Section 23-99-1002 - Definitions

As used in this subchapter:
(1)
"Covered materials" means materials for which reimbursement from the insurer, vision care plan, or vision care discount plan is provided to a vision care provider by an individual's vision benefit plan or contract and that are reimbursable subject to a deductible, copayment, coinsurance, or other contractual limitations;
(2)
"Covered services" means services for which reimbursement from the insurer, vision care plan, or vision care discount plan is provided to a vision care provider by an individual's vision benefit plan or contract and that are reimbursable subject to a deductible, copayment, coinsurance, or other contractual limitations;
(3)
"Insurer" means an insurance company, a health maintenance organization, a hospital and medical service corporation, or a self-insured health plan for employees of a governmental entity;
(4)
"Materials" means ophthalmic devices, including without limitation:
(A)
Lenses;
(B)
Devices containing lenses;
(C)
Artificial intraocular lenses;
(D)
Ophthalmic frames;
(E)
Lens-mounting apparatus;
(F)
Prisms;
(G)
Spectacle or contact lens treatments and coatings; and
(H)
Prosthetic devices to correct, relieve, or treat defects or abnormal conditions of the human eye or its adnexa;
(5)
"Noncovered materials" means materials that are not covered by an insurer, a vision care plan, or a vision care discount plan;
(6)
"Noncovered services" means services that are not covered by an insurer, a vision care plan, or a vision care discount plan;
(7)
"Participating provider agreement" means an agreement between a vision care provider and an insurer that obligates a vision care provider to provide for compensation services and materials to an individual who is insured by the insurer;
(8)
"Services" means benefits or services provided by a vision care provider;
(9)
"Vision benefit plan or contract" means a plan, contract, or policy of insurance issued by an insurer that provides for vision care benefits or services;
(10)
"Vision care discount plan" means a separate plan to provide benefits or services under a rider to a health benefit plan or as a stand-alone agreement that is authorized by a vision care provider to provide discounts to individuals under the Primary Eye Care Provider Act, §
23-99-301
et seq.;
(11)
"Vision care plan" means an entity that provides health benefits and that creates, promotes, sells, provides, advertises, or administers an integrated or stand-alone vision benefit plan or contract; and
(12)
"Vision care provider" means an individual licensed as an optometrist under §
17-90-301
et seq., or a licensed osteopathic or medical physician licensed under §
17-91-101
et seq. or §
17-95-401
et seq., if the physician has also completed a residency in ophthalmology.
Added by Act 2015, No. 959,§ 1, eff. 7/22/2015.
Arkansas Code of 1987 (2023) › Title 23 - PUBLIC UTILITIES AND REGULATED INDUSTRIES (§§ 23-1-101 — 23-119-105) › Subtitle 3 - INSURANCE (§§ 23-60-101 — 23-103-417) › Chapter 99 - HEALTH CARE PROVIDERS (§§ 23-99-201 — 23-99-1802) › Subchapter 10 - VISION CARE PLAN ACT OF 2015 (§§ 23-99-1001 — 23-99-1005) › Section 23-99-1003 - Prohibited practices - Agreements

(a)
A participating provider agreement between an insurer, vision care plan, or vision care discount plan and a vision care provider shall not establish a fee that a vision care provider shall charge for services or materials that are not covered by a vision benefit plan or contract.
(b)
A vision care provider shall not charge a fee for services or materials that is more than the vision care provider's normal rate for the services or materials if the services or materials are noncovered services or noncovered materials.
(c)
(1)
An insurer, vision care plan, or vision care discount plan shall not require a vision care provider to apply a discount to an individual who is insured by the insurer with a participating vision care provider for noncovered services or noncovered materials.
(2)
An insurer, vision care plan, or vision care discount plan shall not avoid the restriction under subdivision (c)(1) of this section by providing minimal reimbursement for a service or materials to apply a discount.
(d)
A participating provider agreement between an insurer, vision care plan, or vision care discount plan and a vision care provider shall not require that a vision care provider participate with or be credentialed by any specific vision care plan or vision care discount plan as a condition to join an insurer's provider panel.
(e)
A participating provider agreement between an insurer, vision care plan, or vision care discount plan and a vision care provider shall not restrict or limit, directly or indirectly, the vision care provider's choice of optical labs or choice of sources and suppliers of services or materials provided by the vision care provider to an individual who is insured by the insurer.
(f)
The terms, discounts, and reimbursement rates in a participating contract between an insurer, vision care plan, or vision care discount plan with a vision care provider shall not be modified during the term of a participating contract absent written authorization from the vision care provider.
(g)
An optician licensed under the Ophthalmic Dispensing Act, §
17-89-101
et seq., is subject to:
(1)
Subsections (c) and (e) of this section; and
(2)
Subsection (b) of this section in regard to materials.
Added by Act 2015, No. 959,§ 1, eff. 7/22/2015.
Arkansas Code of 1987 (2023) › Title 23 - PUBLIC UTILITIES AND REGULATED INDUSTRIES (§§ 23-1-101 — 23-119-105) › Subtitle 3 - INSURANCE (§§ 23-60-101 — 23-103-417) › Chapter 99 - HEALTH CARE PROVIDERS (§§ 23-99-201 — 23-99-1802) › Subchapter 10 - VISION CARE PLAN ACT OF 2015 (§§ 23-99-1001 — 23-99-1005) › Section 23-99-1004 - Private civil action

(a)
A vision care provider adversely affected by any violation of this subchapter by an insurer, vision care plan, or a vision care discount plan may bring a civil action in a court of competent jurisdiction against the insurer, vision care plan, or a vision care discount plan for injunctive relief.
(b)
If a person prevails in the civil action under subsection (a) of this section, the person shall recover:
(1)
Monetary damages not less than one thousand dollars ($1,000);
(2)
Three (3) times the amount of actual damages, if any; and
(3)
Reasonable attorney's fees, costs, and any other proper relief.
Added by Act 2015, No. 959,§ 1, eff. 7/22/2015.
Arkansas Code of 1987 (2023) › Title 23 - PUBLIC UTILITIES AND REGULATED INDUSTRIES (§§ 23-1-101 — 23-119-105) › Subtitle 3 - INSURANCE (§§ 23-60-101 — 23-103-417) › Chapter 99 - HEALTH CARE PROVIDERS (§§ 23-99-201 — 23-99-1802) › Subchapter 10 - VISION CARE PLAN ACT OF 2015 (§§ 23-99-1001 — 23-99-1005) › Section 23-99-1005 - Rules - Enforcement - Effective date

(a)
The State Insurance Department shall develop and promulgate rules for the implementation and administration of this subchapter.
(b)
The Insurance Commissioner shall enforce this subchapter and may seek injunctive relief for violations of this subchapter.
(c)
This subchapter is applicable to a vision benefit plan or contract issued, renewed, or recredentialed in this state on and after July 22, 2015.
Added by Act 2015, No. 959,§ 1, eff. 7/22/2015.
Arkansas Code of 1987 (2023) › Title 23 - PUBLIC UTILITIES AND REGULATED INDUSTRIES (§§ 23-1-101 — 23-119-105) › Subtitle 3 - INSURANCE (§§ 23-60-101 — 23-103-417) › Chapter 99 - HEALTH CARE PROVIDERS (§§ 23-99-201 — 23-99-1802) › Subchapter 11 - PRIOR AUTHORIZATION TRANSPARENCY ACT (§§ 23-99-1101 — 23-99-1130) › Section 23-99-1101 - Title

This subchapter shall be known and may be cited as the "Prior Authorization Transparency Act".
Added by Act 2015, No. 1106,§ 2, eff. 7/22/2015.
Arkansas Code of 1987 (2023) › Title 23 - PUBLIC UTILITIES AND REGULATED INDUSTRIES (§§ 23-1-101 — 23-119-105) › Subtitle 3 - INSURANCE (§§ 23-60-101 — 23-103-417) › Chapter 99 - HEALTH CARE PROVIDERS (§§ 23-99-201 — 23-99-1802) › Subchapter 11 - PRIOR AUTHORIZATION TRANSPARENCY ACT (§§ 23-99-1101 — 23-99-1130) › Section 23-99-1102 - Legislative findings and intent

(a)
The General Assembly finds that:
(1)
A physician-patient relationship is paramount and should not be subject to third-party intrusion; and
(2)
Prior authorizations can place attempted cost savings ahead of optimal patient care.
(b)
The General Assembly intends for this subchapter to:
(1)
Ensure that prior authorizations do not hinder patient care or intrude on the practice of medicine; and
(2)
Guarantee that prior authorizations include the use of written clinical criteria and reviews by appropriate physicians to secure a fair authorization review process for patients.
Added by Act 2015, No. 1106,§ 2, eff. 7/22/2015.
Arkansas Code of 1987 (2023) › Title 23 - PUBLIC UTILITIES AND REGULATED INDUSTRIES (§§ 23-1-101 — 23-119-105) › Subtitle 3 - INSURANCE (§§ 23-60-101 — 23-103-417) › Chapter 99 - HEALTH CARE PROVIDERS (§§ 23-99-201 — 23-99-1802) › Subchapter 11 - PRIOR AUTHORIZATION TRANSPARENCY ACT (§§ 23-99-1101 — 23-99-1130) › Section 23-99-1105 - Prior authorization - Nonurgent healthcare service

(a)
If a utilization review entity requires prior authorization of a nonurgent healthcare service, the utilization review entity shall make an authorization or adverse determination and notify the subscriber and the subscriber's nonurgent healthcare provider of the decision within two (2) business days of obtaining all necessary information to make the authorization or adverse determination.
(b)
For purposes of this section, "necessary information" includes the results of any face-to-face clinical evaluation or second opinion that may be required.
(c)
(1)
If a utilization review entity denies a prior authorization of a nonurgent healthcare service, then the subscriber or the healthcare provider may elect to appeal the denial of the prior authorization of the nonurgent healthcare service.
(2)
If a denial of a prior authorization of a nonurgent healthcare service is appealed to the utilization review entity, then within four (4) business days of receiving all necessary information required, the utilization review entity shall:
(A)
Make an authorization or adverse determination; and
(B)
Notify the subscriber and the healthcare provider that appealed the denial of the prior authorization of the nonurgent healthcare service of the decision.
(3)
This subsection applies to an enrollee who is being evaluated or treated for:
(A)
A hematology diagnosis;
(B)
An oncology diagnosis; or
(C)
An additional disease state or other diagnoses that the Insurance Commissioner may include by rule.
Amended by Act 2023, No. 501,§ 2, eff. 8/1/2023.
Added by Act 2015, No. 1106,§ 2, eff. 7/22/2015.
Arkansas Code of 1987 (2023) › Title 23 - PUBLIC UTILITIES AND REGULATED INDUSTRIES (§§ 23-1-101 — 23-119-105) › Subtitle 3 - INSURANCE (§§ 23-60-101 — 23-103-417) › Chapter 99 - HEALTH CARE PROVIDERS (§§ 23-99-201 — 23-99-1802) › Subchapter 11 - PRIOR AUTHORIZATION TRANSPARENCY ACT (§§ 23-99-1101 — 23-99-1130) › Section 23-99-1106 - Prior authorization - Urgent healthcare service

(a)
A utilization review entity shall render an expedited authorization or adverse determination concerning an urgent healthcare service and notify the subscriber and the subscriber's healthcare provider of that expedited prior authorization or adverse determination no later than one (1) business day after receiving all information needed to complete the review of the requested urgent healthcare service.
(b)
(1)
If a utilization review entity denies a prior authorization of an urgent healthcare service, then the subscriber or the healthcare provider may elect to appeal the denial of the prior authorization of the urgent healthcare service.
(2)
If a denial of a prior authorization of an urgent healthcare service is appealed to the utilization review entity, then within two (2) business days of receiving all necessary information required, the utilization review entity shall:
(A)
Make an authorization or adverse determination; and
(B)
Notify the subscriber and the healthcare provider that appealed the denial of the prior authorization of the urgent healthcare service of the decision.
(3)
This subsection applies to an enrollee who is being evaluated or treated for:
(A)
A hematology diagnosis;
(B)
An oncology diagnosis; or
(C)
An additional disease state or other diagnoses that the Insurance Commissioner may include by rule.
Amended by Act 2023, No. 501,§ 3, eff. 8/1/2023.
Added by Act 2015, No. 1106,§ 2, eff. 7/22/2015.
Arkansas Code of 1987 (2023) › Title 23 - PUBLIC UTILITIES AND REGULATED INDUSTRIES (§§ 23-1-101 — 23-119-105) › Subtitle 3 - INSURANCE (§§ 23-60-101 — 23-103-417) › Chapter 99 - HEALTH CARE PROVIDERS (§§ 23-99-201 — 23-99-1802) › Subchapter 11 - PRIOR AUTHORIZATION TRANSPARENCY ACT (§§ 23-99-1101 — 23-99-1130) › Section 23-99-1107 - Prior authorization - Emergency healthcare service

(a)
A utilization review entity shall not require prior authorization for prehospital transportation or for provision of an emergency healthcare service.
(b)
(1)
A utilization review entity shall allow a subscriber and the subscriber's healthcare provider a minimum of twenty-four (24) hours following an emergency admission or provision of an emergency healthcare service for the subscriber or healthcare provider to notify the utilization review entity of the admission or provision of an emergency healthcare service.
(2)
If the admission or emergency healthcare service occurs on a holiday or weekend, a utilization review entity shall not require notification until the next business day after the admission or provision of the emergency healthcare service.
(c)
(1)
A utilization review entity shall cover emergency healthcare services necessary to evaluate and assess the health condition of a subscriber or to stabilize a subscriber.
(2)
If a healthcare provider certifies in writing to a utilization review entity within seventy-two (72) hours of a subscriber's admission that the subscriber's condition required an emergency healthcare service, that certification will create a presumption that the emergency healthcare service was medically necessary, and such presumption may be rebutted only if the utilization review entity can establish, with clear and convincing evidence, that the emergency healthcare service was not medically necessary.
(d)
(1)
The determination by a utilization review entity of medical necessity of an emergency healthcare service shall not be based on whether the emergency healthcare service was provided by a healthcare provider that is a member of the health benefit plan's provider network.
(2)
Restrictions on coverage for an emergency healthcare service provided by a healthcare provider that is not a member of the health benefit plan's provider network shall not be greater than restrictions on coverage for an emergency healthcare service provided by a healthcare provider that is a member of the health benefit plan's provider network.
(e)
(1)
If a subscriber receives an emergency healthcare service that requires an immediate post-evaluation or post-stabilization healthcare service, a utilization review entity shall make an authorization within sixty (60) minutes of receiving a request.
(2)
If the authorization is not made within sixty (60) minutes, the emergency healthcare service shall be approved.
Amended by Act 2017, No. 815,§ 4, eff. 8/1/2017.
Added by Act 2015, No. 1106,§ 2, eff. 7/22/2015.
Arkansas Code of 1987 (2023) › Title 23 - PUBLIC UTILITIES AND REGULATED INDUSTRIES (§§ 23-1-101 — 23-119-105) › Subtitle 3 - INSURANCE (§§ 23-60-101 — 23-103-417) › Chapter 99 - HEALTH CARE PROVIDERS (§§ 23-99-201 — 23-99-1802) › Subchapter 11 - PRIOR AUTHORIZATION TRANSPARENCY ACT (§§ 23-99-1101 — 23-99-1130) › Section 23-99-1108 - Subscribers with terminal illness - Denial of prior authorization for covered prescription pain medication prohibited

If a subscriber's covered prescription pain medication requires a prior authorization, then the prior authorization shall not be denied if the subscriber has a terminal illness.
Amended by Act 2017, No. 815,§ 5, eff. 8/1/2017.
Added by Act 2015, No. 1106,§ 2, eff. 7/22/2015.
Arkansas Code of 1987 (2023) › Title 23 - PUBLIC UTILITIES AND REGULATED INDUSTRIES (§§ 23-1-101 — 23-119-105) › Subtitle 3 - INSURANCE (§§ 23-60-101 — 23-103-417) › Chapter 99 - HEALTH CARE PROVIDERS (§§ 23-99-201 — 23-99-1802) › Subchapter 11 - PRIOR AUTHORIZATION TRANSPARENCY ACT (§§ 23-99-1101 — 23-99-1130) › Section 23-99-1110 - Waiver prohibited

(a)
The provisions of this subchapter shall not be waived by contract.
(b)
Any contractual arrangements or actions taken in conflict with this subchapter or that purport to waive any requirements of this subchapter are void.
Amended by Act 2017, No. 815,§ 7, eff. 8/1/2017.
Added by Act 2015, No. 1106,§ 2, eff. 7/22/2015.
Arkansas Code of 1987 (2023) › Title 23 - PUBLIC UTILITIES AND REGULATED INDUSTRIES (§§ 23-1-101 — 23-119-105) › Subtitle 3 - INSURANCE (§§ 23-60-101 — 23-103-417) › Chapter 99 - HEALTH CARE PROVIDERS (§§ 23-99-201 — 23-99-1802) › Subchapter 11 - PRIOR AUTHORIZATION TRANSPARENCY ACT (§§ 23-99-1101 — 23-99-1130) › Section 23-99-1112 - Application of subchapter

This subchapter applies to a healthcare insurer, whether or not the healthcare insurer is:
(1)
Acting directly or indirectly through a private utilization review entity; or
(2)
Located in this state.
Amended by Act 2023, No. 87,§ 2, eff. 8/1/2023.
Amended by Act 2017, No. 815,§ 9, eff. 8/1/2017.
Added by Act 2015, No. 1106,§ 2, eff. 7/22/2015.
Arkansas Code of 1987 (2023) › Title 23 - PUBLIC UTILITIES AND REGULATED INDUSTRIES (§§ 23-1-101 — 23-119-105) › Subtitle 3 - INSURANCE (§§ 23-60-101 — 23-103-417) › Chapter 99 - HEALTH CARE PROVIDERS (§§ 23-99-201 — 23-99-1802) › Subchapter 11 - PRIOR AUTHORIZATION TRANSPARENCY ACT (§§ 23-99-1101 — 23-99-1130) › Section 23-99-1113 - Benefit inquiries authorized

(a)
(1)
An in-network or out-of-network healthcare provider may submit a benefit inquiry to a healthcare insurer or utilization review entity for a healthcare service not yet provided to determine whether or not the healthcare service meets medical necessity and all other requirements for payment under a health benefit plan if the healthcare service were to be provided to a specific subscriber.
(2)
(A)
The State Insurance Department shall issue a rule on or before January 1, 2018, that defines which benefits are subject to the requirements of this section.
(B)
Until a rule is promulgated under subdivision (a)(2)(A) of this section, all benefit inquiries shall be processed according to this section.
(b)
If a healthcare insurer or utilization review entity lacks sufficient information to respond to a benefit inquiry, the healthcare insurer or utilization review entity shall notify the healthcare provider within two (2) business days of the additional information that is required to respond to the benefit inquiry.
(c)
(1)
A healthcare insurer, either directly or through a utilization review entity, shall respond to a benefit inquiry authorized in subsection (a) of this section within ten (10) business days of receipt of information required to make a decision on the benefit inquiry.
(2)
Responses to a benefit inquiry shall be provided in the same form and manner as responses to requests for prior authorization.
(d)
Every healthcare insurer shall provide a convenient and accessible procedure for healthcare providers to submit benefit inquiries under this section.
(e)
Sections
23-99-1109
-
23-99-1111
and
23-99-1114
-
23-99-1116
apply to the benefit inquiry process of any healthcare insurer or utilization review entity.
(f)
A healthcare service approved under the benefit inquiry process authorized in this section is not subject to audit recoupment under §
23-63-1801
et seq., except as provided for in §
23-99-1109(b)
.
Amended by Act 2017, No. 815,§ 10, eff. 8/1/2017.
Added by Act 2015, No. 1106,§ 2, eff. 7/22/2015.
Arkansas Code of 1987 (2023) › Title 23 - PUBLIC UTILITIES AND REGULATED INDUSTRIES (§§ 23-1-101 — 23-119-105) › Subtitle 3 - INSURANCE (§§ 23-60-101 — 23-103-417) › Chapter 99 - HEALTH CARE PROVIDERS (§§ 23-99-201 — 23-99-1802) › Subchapter 11 - PRIOR AUTHORIZATION TRANSPARENCY ACT (§§ 23-99-1101 — 23-99-1130) › Section 23-99-1114 - Limitation on step therapy - Definitions

(a)
An insurance policy shall not limit or exclude coverage under the health benefit plan for a drug approved by the United States Food and Drug Administration that is on the prescription drug formulary of the insurance policy by mandating that a covered person undergo step therapy if the insurance policy provides coverage for the treatment of:
(1)
Psychosis and serious mental illness through antipsychotic prescription drugs; and
(2)
Metastatic cancer unless the preferred drug is consistent with best practices that:
(A)
Are used for the treatment of metastatic cancer or associated conditions under:
(i)
United States Food and Drug Administration-approved indication; or
(ii)
The National Comprehensive Cancer Network Drugs and Biologics Compendium indication; or
(B)
Use evidence-based, peer-reviewed, recognized medical literature.
(b)
As used in this section:
(1)
"Metastatic cancer" means cancer that has spread from a primary or original site of the cancer to surrounding or nearby tissues, lymph nodes, or other parts of the body;
(2)
(A)
"Psychosis" means a condition that affects the mind and affects the way the brain processes information.
(B)
"Psychosis" includes delusions and hallucinations; and
(3)
"Serious mental illness" means a mental, behavioral, or emotional disorder resulting in serious functional impairment, that substantially interferes with or limits one (1) or more major life activities.
(c)
For psychosis and serious mental illness, if there is a generic drug equivalent approved by the United States Food and Drug Administration under the same chemical or generic name of a name brand drug that is available, it is not considered step therapy to allow access to and coverage for both the generic drug and the name brand drug.
(d)
If a request for prior authorization is denied due to a step therapy requirement under this section, then the utilization review entity shall authorize the preferred treatment required under the step therapy if a prior authorization for the preferred treatment is required without requiring the healthcare provider to submit a new or revised request.
Amended by Act 2023, No. 577,§ 1, eff. 8/1/2023.
Amended by Act 2023, No. 501,§ 4, eff. 8/1/2023.
Amended by Act 2021, No. 97,§ 5, eff. 7/28/2021.
Amended by Act 2019, No. 699,§ 5, eff. 7/24/2019.
Amended by Act 2019, No. 699,§ 4, eff. 7/24/2019.
Amended by Act 2017, No. 815,§ 11, eff. 8/1/2017.
Added by Act 2015, No. 1106,§ 2, eff. 7/22/2015.
Arkansas Code of 1987 (2023) › Title 23 - PUBLIC UTILITIES AND REGULATED INDUSTRIES (§§ 23-1-101 — 23-119-105) › Subtitle 3 - INSURANCE (§§ 23-60-101 — 23-103-417) › Chapter 99 - HEALTH CARE PROVIDERS (§§ 23-99-201 — 23-99-1802) › Subchapter 11 - PRIOR AUTHORIZATION TRANSPARENCY ACT (§§ 23-99-1101 — 23-99-1130) › Section 23-99-1116 - Failure to comply with subchapter - Requested healthcare services deemed approved

(a)
If a healthcare insurer or utilization review entity fails to comply with this subchapter, the requested healthcare services shall be deemed authorized or approved.
(b)
A healthcare service that is authorized or approved under this section is not subject to audit recoupment under §
23-63-1801
et seq.
Added by Act 2017, No. 815,§ 12, eff. 8/1/2017.
Arkansas Code of 1987 (2023) › Title 23 - PUBLIC UTILITIES AND REGULATED INDUSTRIES (§§ 23-1-101 — 23-119-105) › Subtitle 3 - INSURANCE (§§ 23-60-101 — 23-103-417) › Chapter 99 - HEALTH CARE PROVIDERS (§§ 23-99-201 — 23-99-1802) › Subchapter 11 - PRIOR AUTHORIZATION TRANSPARENCY ACT (§§ 23-99-1101 — 23-99-1130) › Section 23-99-1117 - Standardized form required for prescription drug benefits

(a)
On and after January 1, 2017, to establish uniformity in the submission of prior authorization forms for prescription drugs, a utilization review entity shall utilize only a single standardized prior authorization form for obtaining approval in written or electronic form for prescription drug benefits.
(b)
A utilization review entity may make the form required under subsection (a) of this section accessible through multiple computer operating systems.
(c)
The form required under subsection (a) of this section shall:
(1)
Not exceed two (2) pages; and
(2)
Be designed to be submitted electronically from a prescribing provider to a utilization review entity.
(d)
This section does not prohibit prior authorization by verbal means without a form.
(e)
If a utilization review entity fails to use or accept the form developed under this section or fails to respond as soon as reasonably possible, but no later than seventy-two (72) hours, after receipt of a completed prior authorization request using the form developed under this section, the prior authorization request is deemed authorized or approved.
(f)
(1)
On and after January 1, 2017, each utilization review entity shall submit its prior authorization form to the State Insurance Department to be kept on file.
(2)
A copy of a subsequent replacement or modification of a utilization review entity's prior authorization form shall be filed with the department within fifteen (15) days before the form is used or before implementation of the replacement or modification.
Added by Act 2017, No. 815,§ 12, eff. 8/1/2017.
Arkansas Code of 1987 (2023) › Title 23 - PUBLIC UTILITIES AND REGULATED INDUSTRIES (§§ 23-1-101 — 23-119-105) › Subtitle 3 - INSURANCE (§§ 23-60-101 — 23-103-417) › Chapter 99 - HEALTH CARE PROVIDERS (§§ 23-99-201 — 23-99-1802) › Subchapter 11 - PRIOR AUTHORIZATION TRANSPARENCY ACT (§§ 23-99-1101 — 23-99-1130) › Section 23-99-1118 - Rules

The State Insurance Department may promulgate rules for the implementation of this subchapter.
Added by Act 2017, No. 815,§ 12, eff. 8/1/2017.
Arkansas Code of 1987 (2023) › Title 23 - PUBLIC UTILITIES AND REGULATED INDUSTRIES (§§ 23-1-101 — 23-119-105) › Subtitle 3 - INSURANCE (§§ 23-60-101 — 23-103-417) › Chapter 99 - HEALTH CARE PROVIDERS (§§ 23-99-201 — 23-99-1802) › Subchapter 11 - PRIOR AUTHORIZATION TRANSPARENCY ACT (§§ 23-99-1101 — 23-99-1130) › Section 23-99-1119 - Medication-assisted treatment for opioid addiction

(a)
A healthcare insurer, including Medicaid, shall not:
(1)
Require prior authorization in order for a patient to obtain coverage of buprenorphine, naloxone, naltrexone, methadone, and their various formulations and combinations approved by the United States Food and Drug Administration for the treatment or detoxification of opioid and alcohol addiction; or
(2)
Impose any other requirement other than a valid prescription and compliance with the medication-assisted treatment guidelines issued by the United States Substance Abuse and Mental Health Services Administration under the United States Department of Health and Human Services in order for a patient to obtain coverage for buprenorphine, naloxone, naltrexone, methadone, and their various formulations and combinations approved by the United States Food and Drug Administration for the treatment or detoxification of opioid and alcohol addiction.
(b)
Subdivision (a)(1) of this section shall only apply to the Arkansas Medicaid Program as it pertains to prescription drugs for treatment or detoxification of opioid and alcohol addiction designated as preferred on the evidence-based preferred drug list, provided there is at least one (1) of each of the drugs listed in subdivision (a)(1) of this section with the preferred designation on the preferred drug list or available without prior authorization.
(c)
If a new formulation or medication approved by the United States Food and Drug Administration for use as a prescription for medication-assisted treatment becomes available after April 12, 2019, and is either more expensive or has not been shown to be more effective than the formulations and medications in subsection (a) of this section, then the healthcare insurer may require prior authorization of the new formulation or medication.
(d)
A healthcare insurer utilizing a tiered drug formulary shall place on the lowest-cost benefit tier at least one (1) product for each of the following medications that is approved by the United States Food and Drug Administration:
(1)
Buprenorphine;
(2)
Naloxone;
(3)
Naltrexone;
(4)
Methadone; and
(5)
A product containing both buprenorphine and naloxone.
(e)
For purposes of any limit a healthcare insurer imposes on the number of prescriptions for a patient, a prescription for medication-assisted treatment shall not be counted.
(f)
This section does not affect the responsibility of a healthcare provider to comply with the standard of care for medication-assisted treatment, including without limitation the use of therapy in combination with medication.
(g)
[Repealed.]
Amended by Act 2023, No. 451,§ 1, eff. 8/1/2023.
Added by Act 2019, No. 964,§ 3, eff. 4/12/2019.
Arkansas Code of 1987 (2023) › Title 23 - PUBLIC UTILITIES AND REGULATED INDUSTRIES (§§ 23-1-101 — 23-119-105) › Subtitle 3 - INSURANCE (§§ 23-60-101 — 23-103-417) › Chapter 99 - HEALTH CARE PROVIDERS (§§ 23-99-201 — 23-99-1802) › Subchapter 11 - PRIOR AUTHORIZATION TRANSPARENCY ACT (§§ 23-99-1101 — 23-99-1130) › Section 23-99-1121 - Duration of prior authorization exemption

(a)
Unless a prior authorization exemption is continued for a longer period of time by a healthcare insurer under §
23-99-1120(f)
, a healthcare provider's exemption from prior authorization requirements under §
23-99-1120
remains in effect until the later of:
(1)
The thirtieth day after the date the healthcare insurer notifies the healthcare provider of the healthcare insurer's determination to rescind the exemption as described under §
23-99-1122
, if the healthcare provider does not appeal the healthcare insurer's determination within thirty (30) days of notification of the determination;
(2)
If the healthcare provider appeals the determination within thirty (30) days of notification of the determination, the fifth day after the date an independent review organization affirms the healthcare insurer's determination to rescind the exemption; or
(3)
Twelve (12) months after the effective date of the exemption.
(b)
If a healthcare provider appeals the determination to rescind the exemption more than thirty (30) days after notification of the determination and the independent review organization overturns the rescission, the healthcare provider's exemption is restored the fifth day after the date of the independent review organization's decision, and the exemption remains in effect for twelve (12) months after restoration unless rescinded under §
23-99-1122
.
(c)
If a healthcare insurer does not finalize a rescission determination as specified in subsection (a) of this section, then the healthcare provider is considered to have met the criteria under §
23-99-1120
to continue to qualify for the exemption.
(d)
A healthcare provider shall not rely on another healthcare provider's exemption except when the healthcare provider with an exemption is the healthcare provider that orders healthcare services that are rendered by a healthcare provider without an exemption.
Added by Act 2023, No. 575,§ 5, eff. 8/1/2023.
Arkansas Code of 1987 (2023) › Title 23 - PUBLIC UTILITIES AND REGULATED INDUSTRIES (§§ 23-1-101 — 23-119-105) › Subtitle 3 - INSURANCE (§§ 23-60-101 — 23-103-417) › Chapter 99 - HEALTH CARE PROVIDERS (§§ 23-99-201 — 23-99-1802) › Subchapter 11 - PRIOR AUTHORIZATION TRANSPARENCY ACT (§§ 23-99-1101 — 23-99-1130) › Section 23-99-1123 - Independent review of exemption determination

(a)
(1)
A healthcare provider has a right to a review of an adverse determination regarding a prior authorization exemption within twelve (12) months of receiving proper notice of recission from a healthcare insurer to be conducted by an independent review organization.
(2)
A healthcare insurer shall not require a healthcare provider to engage in an internal appeal process before requesting a review by an independent review organization under this section.
(3)
A healthcare provider who has an exemption rescinded due to a failure to provide medical records within sixty (60) days of a record request for a retrospective review shall not be eligible for review of that rescission by an independent review entity.
(b)
A healthcare insurer shall pay:
(1)
For any appeal or independent review of an adverse determination regarding a prior authorization exemption requested under this section; and
(2)
A reasonable fee determined by the Arkansas State Medical Board for any copies of medical records or other documents requested from a healthcare provider during an exemption rescission review requested under this section.
(c)
An independent review organization shall complete an expedited review of an adverse determination regarding a prior authorization exemption no later than the thirtieth day after the date a healthcare provider files the request for a review under this section.
(d)
(1)
A healthcare provider may request that the independent review organization consider another random sample of no fewer than five (5) and no more than twenty (20) claims submitted to the healthcare insurer by the healthcare provider during the relevant evaluation period for the relevant healthcare service as part of the review under this section.
(2)
If a healthcare provider makes a request under subdivision (d)(1) of this section, the independent review organization shall base its determination on the medical necessity of claims reviewed:
(A)
By the healthcare insurer under §
23-99-1122
; and
(B)
By the independent review organization under subdivision (d)(1) of this section.
(e)
The Insurance Commissioner may refuse, suspend, revoke, or not renew a license or certificate of authority of a healthcare insurer that has fifty percent (50%) of healthcare provider appeals overturned in a twelve-month period by an independent review organization under this section.
Added by Act 2023, No. 575,§ 5, eff. 8/1/2023.
Arkansas Code of 1987 (2023) › Title 23 - PUBLIC UTILITIES AND REGULATED INDUSTRIES (§§ 23-1-101 — 23-119-105) › Subtitle 3 - INSURANCE (§§ 23-60-101 — 23-103-417) › Chapter 99 - HEALTH CARE PROVIDERS (§§ 23-99-201 — 23-99-1802) › Subchapter 11 - PRIOR AUTHORIZATION TRANSPARENCY ACT (§§ 23-99-1101 — 23-99-1130) › Section 23-99-1124 - Effect of appeal of independent review organization determination

(a)
A healthcare insurer is bound by an appeal or independent review organization determination that does not affirm the determination made by the healthcare insurer to rescind a prior authorization exemption.
(b)
A healthcare insurer shall not retroactively deny a healthcare service on the basis of a rescission of an exemption, even if the healthcare insurer's determination to rescind the prior authorization exemption is affirmed by an independent review organization.
(c)
If a determination of a prior authorization exemption made by the healthcare insurer is overturned on review by an independent review organization, the healthcare insurer:
(1)
Shall not attempt to rescind the exemption before the end of the next evaluation period; and
(2)
May only rescind the exemption if the healthcare insurer complies with §§
23-99-1122
and
23-99-1123
.
Added by Act 2023, No. 575,§ 5, eff. 8/1/2023.
Arkansas Code of 1987 (2023) › Title 23 - PUBLIC UTILITIES AND REGULATED INDUSTRIES (§§ 23-1-101 — 23-119-105) › Subtitle 3 - INSURANCE (§§ 23-60-101 — 23-103-417) › Chapter 99 - HEALTH CARE PROVIDERS (§§ 23-99-201 — 23-99-1802) › Subchapter 11 - PRIOR AUTHORIZATION TRANSPARENCY ACT (§§ 23-99-1101 — 23-99-1130) › Section 23-99-1125 - Eligibility for prior authorization exemption following finalized exemption rescission or denial

(a)
After a final determination or review affirming the rescission or denial of an exemption for a specific healthcare service under §
23-99-1120
, a healthcare insurer shall conduct another evaluation to determine whether or not the exemption should be granted or reinstated based on the six-month evaluation period that follows the evaluation period that formed the basis of the rescission or denial of an exemption.
(b)
A time period that is included in a previous evaluation or determination period shall not be included in a subsequent evaluation period.
Added by Act 2023, No. 575,§ 5, eff. 8/1/2023.
Arkansas Code of 1987 (2023) › Title 23 - PUBLIC UTILITIES AND REGULATED INDUSTRIES (§§ 23-1-101 — 23-119-105) › Subtitle 3 - INSURANCE (§§ 23-60-101 — 23-103-417) › Chapter 99 - HEALTH CARE PROVIDERS (§§ 23-99-201 — 23-99-1802) › Subchapter 11 - PRIOR AUTHORIZATION TRANSPARENCY ACT (§§ 23-99-1101 — 23-99-1130) › Section 23-99-1128 - Prescription drugs, medicines, biological products, pharmaceuticals, or pharmaceutical services

(a)
(1)
Beginning on January 1, 2024, a healthcare insurer or pharmacy benefits manager shall submit a written request to the Arkansas State Board of Pharmacy for any prescription drug, medicine, biological product, pharmaceutical, or pharmaceutical service to be reviewed for a continuation of prior authorization by a specified health benefit plan whether or not a healthcare provider has met the criteria for an exemption from prior authorization under §§
23-99-1120
-
23-99-1126
.
(2)
The request under subdivision (a)(1) of this section shall state the reason the request is being made for each prescription drug, medicine, biological product, pharmaceutical, or pharmaceutical service for the specified health benefit plan.
(b)
The Arkansas State Board of Pharmacy and the Arkansas State Medical Board, jointly, may establish criteria and procedures to review whether a request made under subdivision (a)(1) of this section should be granted for the requesting party and specified health benefit plan.
(c)
(1)
The Arkansas State Board of Pharmacy and the Arkansas State Medical Board, jointly, may determine whether or not a prescription drug, medicine, biological product, pharmaceutical, or pharmaceutical service may be subject to prior authorization by a health benefit plan under the criteria and procedures under subsection (b) of this section.
(2)
The Arkansas State Board of Pharmacy shall promptly notify the entity that made the request of the joint decision made by the Arkansas State Board of Pharmacy and the Arkansas State Medical Board.
(d)
The Arkansas State Board of Pharmacy shall make available to any person who requests it, a list for any health benefit plan of prescription drugs, medicines, biological products, pharmaceuticals, or pharmaceutical services that require a prior authorization under this section.
Added by Act 2023, No. 575,§ 5, eff. 8/1/2023.
Arkansas Code of 1987 (2023) › Title 23 - PUBLIC UTILITIES AND REGULATED INDUSTRIES (§§ 23-1-101 — 23-119-105) › Subtitle 3 - INSURANCE (§§ 23-60-101 — 23-103-417) › Chapter 99 - HEALTH CARE PROVIDERS (§§ 23-99-201 — 23-99-1802) › Subchapter 11 - PRIOR AUTHORIZATION TRANSPARENCY ACT (§§ 23-99-1101 — 23-99-1130) › Section 23-99-1129 - Appeals process for disallowance of prior authorization

(a)
If the Arkansas State Board of Pharmacy and the Arkansas State Medical Board, jointly, disallow a prior authorization of a prescription drug, medicine, biological product, pharmaceutical, or pharmaceutical service requested under §
23-99-1128
, a healthcare insurer, pharmacy benefits manager, or other interested party may file an appeal to the State Insurance Department within ninety (90) days of the disallowance of the prior authorization.
(b)
No later than the thirtieth day after the date a healthcare insurer, pharmacy benefits manager, or other interested party files an appeal under subsection (a) of this section, the Insurance Commissioner shall appoint an independent review organization to review the appeal.
(c)
A healthcare insurer, pharmacy benefits manager, or other interested party that files an appeal under subsection (a) of this section shall pay for the independent review organization appointed under subsection (b) of this section to review the appeal.
(d)
A healthcare insurer, pharmacy benefits manager, or other interested party is bound by the independent review organization's determination of the appeal under this section.
Added by Act 2023, No. 575,§ 5, eff. 8/1/2023.