Federal Laws

Find out what rights you and your patients have under current federal statutes and regulations, such as the Employee Retirement Income Security Act and the Medicare Advantage program.

Federal Law

Title 42-Chapter IV-Subchapter B-Part 422-Subpart C. Benefits and Beneficiary Protections

08/30/2023 Section 422.101

Requirements relating to basic benefits

Medical Necessity-Definition, U.R. Criteria
State Law

Georgia Code-Title 33-Chapter 46-Certification of Private Review Agents. Article 1. General Provisions

08/01/2023 Georgia Section 33-46-6

Requirements for Certification; Utilization of Nationally Recognized Accreditation Standards; Website Identifying Nationally Recognized Accreditation Entities

U.R. Criteria
State Law

Code of Massachusetts Regs-Title 958-Part 3. Health Insurance Consumer Protection

07/26/2023 Massachusetts Sections 958 CMR 3.020, 3.100, 3.101, 3.305, 3.306, 3.309, 3.310, and 3.311

Definitions; Clinical Decisions; Carrier’s Medical Necessity Guidelines; Time Limits for Resolution of Non-expedited Internal Grievances; Review of Internal Grievances; Expedited Internal Review of Adverse Determinations; Additional Requirements for Expedited Internal Review; Failure of Carrier to Meet Time Limits

Medical Necessity-Definition, State Medical Necessity Appeals-Deadlines, U.R. Criteria
State Law

LA. Rev. Statutes-Title 22-Insurance. Utilization Review Standards

07/16/2023 Louisiana Sections 22:1260.41 through 1260.48

Definitions; Documented prior authorization program, requirements; Timeframes for determinations, concurrent review, retrospective review, adverse determination; Documentation; Utilization review, determinations, appeals; Prior authorization, denial of claims; Reviews for fraud, waste or abuse

Retroactive Denial, State Medical Necessity Decisions-Deadlines, U.R. Criteria
State Law

Revised Code of Washington-Title 48-Chapter 48.43. Insurance Reform

07/10/2023 Washington Section to be added under Chapter 48.43

Prior authorization

State Medical Necessity Decisions-Deadlines, U.R. Criteria
State Law

Tennessee Code-Title 56-Chapter 7- Part 36. Prior Authorization Fairness Act

07/08/2023 Tennessee Sections 3601-3622

Short title; Part definitions; Requirements for initial adverse determinations; Appeals of an electronic and non-electronic initial adverse determination; Prior authorization submissions; Chronic conditions; Clinical criteria; Electronic prior authorization; Expiration date for a prior authorization; Prior authorization and opioid use disorder; Medical necessity; Changing prior authorization requirements; Payment; Prior authorization transfers; Related service; Reviewer criteria; Statistics; Prior authorization requirements; Website notice requirements; Applicability; Provider notification to health carrier; Rules.

Amendments, State Medical Necessity Decisions-Deadlines, U.R. Criteria
State Law

West Virginia Code-Chapter 33-Article 16-Group Accident and Sickness Insurance

07/10/2023 West Virginia Section 33-16-3dd

Prior authorization

State Medical Necessity Appeals-Deadlines, State Medical Necessity Decisions-Deadlines, U.R. Criteria
State Law

The Insurance Company Law of 1921 (P.L.682, No.284)

08/22/2023 Pennsylvania Sections 2102, 2152, 2154 and 2155

Definitions; Operational standards; Medical policies and clinical review criteria; Prior authorization review

State Medical Necessity Decisions-Deadlines, U.R. Criteria
Ama Policy

Fair Reimbursement for Administrative Burdens D-320.978

Payment Edits, U.R. Criteria