Arkansas Administrative Code › Agency 054 - Arkansas Insurance Department › Rule 054.00.16-002 - 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.
			 §§
								23-61-108(a)(1),
			 23-61-108(b)(1)
			 and
			 23-99-414.
Section 2.
Purpose
The purpose of this Rule is to implement Act 1106 of 2015 of the
			 Arkansas 90th General Assembly, "An Act To Establish
			 Prior Authorization Transparency" (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 and consistent
			 with state law, 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.
Section 5.
Publication of
		  Prior Authorization and Nonmedical Review Criteria & Statistics
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)
		  on and after the effective date of the Prior Authorization Transparency Act,
		  which is July 22, 2015, and is not required to disclose statistical information
		  from the time prior to the effective date of that Act.
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(a)(1)
		  related to the disclosure by a utilization review entity of non-medical review
		  requirements and restrictions, the term "non-medical review," as defined in
		  Ark. Code Ann. §
									23-99-1103(15),
		  refers to the deadlines, filing procedures, or other administrative
		  requirements of the utilization review entity for a provider to obtain or
		  qualify for a prior authorization.
6. 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.
7.
Publication of "Proprietary"
		  Medical Clinical Criteria
. Pursuant to Ark. Code Ann. §
									23-99-1104(a)(1),
		  a utilization review entity shall post all of its prior authorization and
		  nonmedical review requirements and restrictions, including any written clinical
		  criteria, on the public part of its website. However, for insurers or
		  utilization review entities, which have, by contract with vendors or
		  third-party administrators, agreed to use licensed, proprietary or copyright
		  protected clinical criteria from such vendors or administrators, a utilization
		  review entity may, as an alternative means of compliance, make all relevant
		  proprietary clinical criteria available to any medical providers submitting a
		  prior authorization request to the utilization review entity, both for
		  in-network and out of network providers, via a link accessible to the provider
		  from the public part of its website as long as any link or access restrictions
		  to such information causes no delay to the provider.
8.
Deemer Provision
.
		  Pursuant to Ark. Code Ann. §
									23-99-1113,
		  if a utilization review entity fails to comply with the provisions of the Prior
		  Authorization Transparency Act, the requested healthcare services shall be
		  deemed authorized or approved. This provision however only deems approved the
		  healthcare services which are the subject of the prior authorizations or
		  nonmedical review which failed to follow the requirements of the Act and does
		  not deem approved all denials which follow the provisions of this
		  Act.