House Bill 780

AN ACT TO CREATE NEW SECTIONS 83-41-501 THROUGH 83-41-517, MISSISSIPPI CODE OF 1972, TO AUTHORIZE AN EXEMPTION FROM PRIOR AUTHORIZATION REQUIREMENTS BY HEALTH INSURERS FOR PHYSICIANS AND OTHER PROVIDERS WHO PROVIDE CERTAIN HEALTH CARE SERVICES; TO PROVIDE THAT A HEALTH INSURER THAT USES A PRIOR AUTHORIZATION PROCESS FOR HEALTH CARE SERVICES MAY NOT REQUIRE A PHYSICIAN OR OTHER PROVIDER TO OBTAIN PRIOR AUTHORIZATION FOR A PARTICULAR HEALTH CARE SERVICE IF, IN THE MOST RECENT SIX-MONTH EVALUATION PERIOD, THE HEALTH INSURER HAS APPROVED OR WOULD HAVE APPROVED NOT LESS THAN 90 PERCENT OF THE PRIOR AUTHORIZATION REQUESTS SUBMITTED FOR THE PARTICULAR HEALTH CARE SERVICE; TO AUTHORIZE A HEALTH INSURER TO RESCIND AN EXEMPTION FROM PRIOR AUTHORIZATION REQUIREMENTS ONLY IF THE HEALTH INSURER MAKES A DETERMINATION, ON THE BASIS OF A RETROSPECTIVE REVIEW OF A RANDOM SAMPLE OF CLAIMS SUBMITTED BY THE PHYSICIAN OR OTHER PROVIDER DURING THE MOST RECENT EVALUATION PERIOD, THAT LESS THAN 90 PERCENT OF THE CLAIMS FOR THE PARTICULAR HEALTH CARE SERVICE MET THE MEDICAL NECESSITY CRITERIA THAT WOULD HAVE BEEN USED BY THE HEALTH INSURER WHEN CONDUCTING PRIOR AUTHORIZATION REVIEW FOR THE PARTICULAR HEALTH CARE SERVICE DURING THE RELEVANT EVALUATION PERIOD; TO PROVIDE THAT SUCH A DETERMINATION MUST BE MADE BY AN INDIVIDUAL LICENSED TO PRACTICE MEDICINE IN THIS STATE; TO PROVIDE THAT A PHYSICIAN OR OTHER PROVIDER HAS A RIGHT TO A REVIEW OF AN ADVERSE DETERMINATION REGARDING A DENIAL OR RESCISSION OF A PRIOR AUTHORIZATION EXEMPTION AND THAT THE REVIEW MUST BE CONDUCTED BY AN ACCREDITED INDEPENDENT REVIEW ORGANIZATION; TO PROVIDE THAT A HEALTH INSURER SHALL PAY FOR ANY APPEAL OR INDEPENDENT REVIEW OF AN ADVERSE DETERMINATION REGARDING A PRIOR AUTHORIZATION EXEMPTION REQUESTED BY A PHYSICIAN OR OTHER PROVIDER; TO PROVIDE THAT A HEALTH INSURER IS BOUND BY AN APPEAL OR INDEPENDENT REVIEW DETERMINATION THAT DOES NOT AFFIRM THE DETERMINATION MADE BY THE HEALTH INSURER TO RESCIND OR DENY A PRIOR AUTHORIZATION EXEMPTION; TO PROVIDE THAT A HEALTH INSURER SHALL NOT DENY OR REDUCE PAYMENT TO A PHYSICIAN OR OTHER PROVIDER FOR A HEALTH CARE SERVICE FOR WHICH THE PHYSICIAN OR OTHER PROVIDER HAS QUALIFIED FOR AN EXEMPTION FROM PRIOR AUTHORIZATION REQUIREMENTS BASED ON MEDICAL NECESSITY OR APPROPRIATENESS OF CARE, UNLESS THE PHYSICIAN OR OTHER PROVIDER KNOWINGLY AND MATERIALLY MISREPRESENTED THE HEALTH CARE SERVICE IN A REQUEST FOR PAYMENT SUBMITTED TO THE HEALTH INSURER WITH THE SPECIFIC INTENT TO DECEIVE AND OBTAIN AN UNLAWFUL PAYMENT FROM THE HEALTH INSURER, OR FAILED TO SUBSTANTIALLY PERFORM THE HEALTH CARE SERVICE; TO AMEND SECTIONS 41-83-9, 41-83-31, 73-23-35, 83-9-6.3, 83-9-32, 83-9-353, 83-41-409 AND 83-51-15, MISSISSIPPI CODE OF 1972, TO CONFORM TO THE PROVISIONS OF THIS ACT; AND FOR RELATED PURPOSES.

In the House of Representatives

• Sam C. Mims, V

  Sponsor

l9n doesn't hold this bill's text yet.

In the House of Representatives Jan 17 – Feb 1

1. Jan 17Referred to the House committee on Public Health and Human Services
2. Feb 1Died in committee in the House