Arkansas Administrative Code › Agency 054 - Arkansas Insurance Department › Rule 054.00.17-004 - Rule 115: Prior Authorization Transparency Act

Current through Register Vol. 49, No. 6, June, 2024
Section 1.
Authority
This Rule is issued pursuant to the authority granted the
			 Arkansas Insurance Commissioner ("Commissioner") under Ark. Code Ann.
			 §§
								23-99-1118,
			 23-99-1113(a)(2)(A),
			 23-61-108(a)(1),
			 and
			 23-61-108(b)(1).
Section 2.
Purpose
The purpose of this Rule is to implement Act 815 of 2017 of the
			 91st Arkansas General Assembly, "An Act To Clarify
			 Certain Provisions Of The Prior Authorization Transparency Act (hereafter, the
			 "Prior Authorization Transparency Act").
Section 3.
Applicability and
		  Scope
This Rule applies to all health benefit plans as defined in Ark.
			 Code Ann. §
								23-99-1103(7).
Section 4.
Definitions
Unless otherwise separately defined in this rule, the terms or
			 phrases as used in this rule shall follow the definitions of such terms or
			 phrases as defined in Ark. Code Ann. §
								23-99-1103, or as
			 later amended in the Prior Authorization Transparency Act subchapter.
"Benefit Inquiry" means an inquiry by an Arkansas licensed
			 healthcare provider to a utilization review entity related to medical
			 necessity, coverage or payment for prospective healthcare services, including
			 prescription drugs, for an enrolled member of a healthcare plan of the
			 applicable healthcare insurer for services or prescription drugs which are not
			 subject to prior authorization requirements of the utilization review
			 entity.
Section 5.
Publication of Prior Authorization and Nonmedical Review Criteria &
		  Statistics
A utilization review entity shall follow the disclosure
			 requirements under Ark. Code Ann. §
									23-99-1104.
A.
Updating Statistical Reporting Data
		  Required Under Ark. Code Ann. §
									23-99-1104.
For the statistical reporting data required under Ark. Code Ann.
			 §
									23-99-1104(d),
			 a utilization review entity shall update the required statistics in the format
			 and manner as required by Ark. Code Ann. §
									23-99-1104(d)
			 once each quarter of each year from the effective date of this Rule.
B.
Effective Date For
		  Reporting, Retention of Statistical Information & Application of Statistics
		  and Clinical Criteria.
1. A
		  utilization review entity is required to disclose the statistical information
		  required under Ark. Code Ann. §
									23-99-1104(d)
		  for statistics from health benefit plans occurring on and after July 22,
		  2015.
2. A utilization review
		  entity shall disclose and maintain the statistical information as required
		  under Ark. Code Ann. §
									23-99-1104(d)
		  for at least a three (3) year rolling time period.
3. A utilization review entity is required to
		  disclose statistical reporting data under Ark. Code Ann. §
									23-99-1104(d)
		  for Arkansas resident insureds in the individual market or Arkansas resident
		  enrollees or certificate holders in health benefit plans as defined under Ark.
		  Code Ann. §
									23-99-1103(7).
4. For purposes of interpretation of Ark.
		  Code Ann. §
									23-99-1104(d)(2)(A)
		  related to the disclosure of prior authorization data, the term, "physician
		  specialty" refers to the medical specialty of the treating physician who has
		  submitted the prior authorization request and not to the specialty of the
		  medical reviewer of the utilization review entity. A utilization review entity
		  shall disclose the physician specialty data to the extent that the utilization
		  review entity has received physician specialty information at the time the
		  prior authorization request is submitted.
5. For purposes of interpretation of Ark.
		  Code Ann. §
									23-99-1104(d)(2)(C),
		  related to the disclosure of prior authorization data, the term, "indication
		  offered," means the medical indication, i.e., relevant diagnosis, given by the
		  healthcare provider for the medication, test, or procedure.