Rep. Norm Thurston — Voting Record

Bill

Number

S.B. 274 (2025GS)

Sponsor

Sen. Johnson, John D.

Final action

Governor Signed 3/27/2025

Outcome

Became law — signed by Gov. Spencer J. Cox

Summary

What it does

• This bill:
• requires health insurers to provide information related to preauthorization to the Department of Insurance, patients, and health care providers; and
• creates a repeal date.

Every vote on this bill

Bill text

5
31A-22-650
63I-1-231
0
Health Insurance Preauthorization Revisions
2025 GENERAL SESSION
STATE OF UTAH
Chief Sponsor: John D. Johnson
House Sponsor: Katy Hall
LONG TITLE
General Description:
This bill amends provisions related to health insurance preauthorization.
Highlighted Provisions:
This bill:
requires health insurers to provide information related to preauthorization to the 
Department of Insurance, patients, and health care providers; and
creates a repeal date.
Money Appropriated in this Bill:
None
Other Special Clauses:
None
Utah Code Sections Affected:
AMENDS:
31A-22-650
, as enacted by Laws of Utah 2019, Chapter 439
63I-1-231
, as last amended by Laws of Utah 2023, Chapter 28
Be it enacted by the Legislature of the state of Utah:
Section 1, Section 
31A-22-650
 is amended to read:
31A-22-650
. Health care preauthorization requirements.
(1)
As used in this section:
(a)
"Adverse preauthorization determination" means a determination by an insurer that 
health care does not meet the preauthorization requirement for the health care.
(b)
"Authorization" means a determination by an insurer that for health care with a 
preauthorization requirement:
(i)
the proposed drug, device, or covered service meets all requirements, restrictions, 
limitations, and clinical criteria for authorization established by the insurer;
(ii)
the drug, device, or covered service is covered by the enrollee's insurance policy; 
and
(iii)
the insurer will provide coverage for the drug, device, or covered service subject 
to the provisions of the insurance policy, including any cost sharing 
responsibilities of the enrollee.
(c)
"Device" means a prescription device as defined in Section 
58-17b-102
.
(d)
"Drug" means the same as that term is defined in Section 
58-17b-102
.
(e)
"Insurer" means the same as that term is defined in Section 
31A-22-634
.
(f)
"Preauthorization requirement" means a requirement by an insurer that an enrollee 
obtain authorization for a drug, device, or service covered by the insurance policy, 
before receiving the drug, device, or service.
(2)
(a)
An insurer may not modify an existing requirement for authorization unless, at 
least 30 days before the day on which the modification takes effect, the insurer:
(i)
posts a notice of the modification on the website described in Subsection 
31A-22-613.5(6)(a)
; and
(ii)
if requested by a network provider or the network provider's representative, 
provides to the network provider by mail or email a written notice of modification 
to a particular requirement for authorization described in the request from the 
network provider.
(b)
Subsection 
(2)(a)
 does not apply if:
(i)
complying with Subsection 
(2)(a)
 would create a danger to the enrollee's health or 
safety; or
(ii)
the modification is for a newly covered drug or device.
(c)
An insurer may not revoke an authorization for a drug, device, or covered service if:
(i)
the network provider submits a request for authorization for the drug, device, or 
covered service to the insurer;
(ii)
the insurer grants the authorization requested under Subsection 
(2)(c)(i)
;
(iii)
the network provider renders the drug, device, or covered service to the enrollee 
in accordance with the authorization and any terms and conditions of the network 
provider's contract with the insurer;
(iv)
on the day on which the network provider renders the drug, device, or covered 
service to the enrollee:
(A)
the enrollee is eligible for coverage under the enrollee's insurance policy; and
(B)
the enrollee's condition or circumstances related to the enrollee's care have not 
changed;
(v)
the network provider submits an accurate claim that matches the information in 
the request for authorization under Subsection 
(2)(c)(i)
; and
(vi)
the authorization was not based on fraudulent or materially incorrect information 
from the network provider.
(3)
(a)
An insurer that receives a request for authorization shall treat the request as a 
pre-service claim as defined in 29 C.F.R. Sec. 2560.503-1 and process the request in 
accordance with:
(i)
29 C.F.R. Sec. 2560.503-1, regardless of whether the coverage is offered through 
an individual or group health insurance policy;
(ii)
Subsection 
31A-4-116(2)
; and
(iii)
Section 
31A-22-629
.
(b)
If a network provider submits a claim to an insurer that includes an unintentional 
error that results in a denial of the claim, the insurer shall permit the network 
provider with an opportunity to resubmit the claim with corrected information within 
a reasonable amount of time.
(c)
Except as provided in Subsection 
(3)(d)
, the appeal of an adverse preauthorization 
determination regarding clinical or medical necessity as requested by a physician 
may only be reviewed by a physician who is currently licensed as a physician and 
surgeon in a state, district, or territory of the United States.
(d)
The appeal of an adverse determination requested by a physician regarding clinical 
or medical necessity of a drug, may only be reviewed by an individual who is 
currently licensed in a state, district, or territory of the United States as:
(i)
a physician and surgeon; or
(ii)
a pharmacist.
(e)
An insurer shall ensure that an adverse preauthorization determination regarding 
clinical or medical necessity is made by an individual who:
(i)
has knowledge of the medical condition or disease of the enrollee for whom the 
authorization is requested; or
(ii)
consults with a specialist who has knowledge of the medical condition or disease 
of the enrollee for whom the authorization is requested regarding the request 
before making the determination.
(f)
An insurer shall specify how long an authorization is valid.
(4)
(a)
An insurer that removes a drug from the insurer's formulary shall:
(i)
permit an enrollee, an enrollee's designee, or an enrollee's network provider to 
request an exemption from the change to the formulary for the purpose of 
providing the patient with continuity of care; and
(ii)
have a process to review and make a decision regarding an exemption requested 
under Subsection 
(4)(a)(i)
.
(b)
If an insurer makes a change to the formulary for a drug in the middle of a plan year, 
the insurer may not implement the changes for an enrollee that is on an active course 
of treatment for the drug unless the insurer provides the enrollee with notice at least 
30 days before the day on which the change is implemented.
(5)
(a)
Before April 1, 2021, and before April 1 of each year thereafter, 
Each April 1, 
an insurer with a preauthorization requirement shall report to the department, for the 
previous calendar year, the percentage of authorizations, not including a claim 
involving urgent care as defined in 29 C.F.R. Sec. 2560.503-1, for which the insurer 
notified a provider regarding an authorization or adverse preauthorization 
determination more than one week after the day on which the insurer received the 
request for authorization.
(b)
Before March 1, 2026, and each March 1 thereafter, an insurer shall report to the 
department the following for the previous calendar year:
(i)
a list of services that have preauthorization requirements;
(ii)
for pre-service preauthorization requests that were not urgent, the percentage of 
individual service requests that:
(A)
were approved;
(B)
were denied;
(C)
were approved after appeal;
(D)
the time frame for review was extended, and the request was approved;
(E)
were denied due to incomplete information from the health care provider; and
(F)
were received through fax, phone, and electronic portal; and
(iii)
for urgent pre-service preauthorization requests, the percentage of individual 
service requests that:
(A)
were approved;
(B)
were denied;
(C)
were denied due to incomplete information from the health care provider; and
(D)
were received through fax, phone, and electronic portal.
(c)
Data provided to the department under Subsections 
(5)
(b)(ii) and (iii) shall be 
aggregated for all services.
(d)
Subsection 
(5)
(b) does not require an insurer to report information regarding 
prescription drugs.
(e)
The department shall compile the information described in Subsection (5)(b) and 
publish the information on the department's website.
(6)
An insurer may not have a preauthorization requirement for emergency health care as 
described in Section 
31A-22-627
.
(7)
For each adverse preauthorization determination made by an insurer, the insurer shall 
provide to the enrollee and the enrollee's health care provider:
(a)
a detailed and specific explanation that explains why the determination was made; 
and
(b)
a notice explaining the determination may be appealed and the process for appealing 
the determination, including how to begin an expedited appeal process as described 
in Section 
31A-22-629
.
(8)
In accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act, the 
department may make rules to implement Subsection 
(5)(b)
.
Section 2, Section 
63I-1-231
 is amended to read:
63I-1-231
. Repeal dates: Title 31A.
(1)
Section 
31A-2-217
, Coordination with other states, is repealed July 1, 2033.
(2)
Subsection 
31A-22-650(5)(b)
, regarding the reporting requirement that includes the 
number of preauthorizations that were approved and denied, is repealed July 1, 2029.
(3)
Subsection 
31A-22-650(8)
, regarding the rulemaking for the preauthorization reporting 
requirement, is repealed July 1, 2029.
Section 3. 
Effective Date.
This bill takes effect on 
May 7, 2025
.
3-7-25 8:40 AM