Prior authorization.

Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care, and makes a willful violation of the act a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law generally authorizes a health care service plan or health insurer to use prior authorization and other utilization review or utilization management functions, under which a licensed physician or a licensed health care professional who is competent to evaluate specific clinical issues may approve, modify, delay, or deny requests for health care services based on medical necessity. Existing law requires a health care service plan or health insurer, including those plans or insurers that delegate utilization review or utilization management functions to medical groups, independent practice associations, or other contracting providers, to comply with specified requirements and limitations on their utilization review or utilization management processes. This bill would require a health care service plan or health insurer that implements an automated prior authorization system to use evidence-based clinical guidelines to program the system and to make the algorithms used for the system available for download on the plan's or insurer's provider internet website. The bill would require a plan or insurer that implements an automated prior authorization system to ensure that a licensed physician or a licensed health care professional makes the decision to deny or modify a request by examining the request specific to the enrollee or insured and does not simply ratify an automated response. This bill would prohibit a health care service plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2022, that provides coverage for a specified service, including chiropractic services, physical or occupational therapy, and acupuncture and traditional medicine, from requiring prior authorization for the initial 12 treatment visits for that service within a new episode of care. Because a willful violation of the bill's requirements relative to health care service plans would be a crime, the bill would impose a state-mandated local program. The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement. This bill would provide that no reimbursement is required by this act for a specified reason.