State Laws

Search state statutes and regulations in all 50 states and the District of Columbia to find out what rights you have in your state and what other states are doing to empower physicians and patients in the face of health insurer market power.

State Law

New Jersey Statutes-Title 17B. Insurance

06/20/2024 New Jersey Sections 17B:30-55.1 through 17B:30-56

Short title; Findings, declarations; Definitions; Payer, information, utilization management, processing, payment of claims; Payer, respond, hospital, health care provider request, prior authorization; Carrier, respond, prior authorization requests, medication coverage submitted, NCPDP SCRIPT Standard for ePA transactions; Prior authorization, chronic, long-term care condition, validity, exception, timeline; Prior authorization, denial, limitation imposed by payer, physician, scope of actions; Prior authorization, defined number, discrete services, set time frame, validity, exception; Payer to honor prior authorization granted to covered person by previous payer, initial coverage, upon receipt of documentation; Denial of prior authorization, communicated via written communication agreed to by payer, hospital, health care provider; Adverse determinations, appeal, reviewed by physician; Payer shall not deny reimbursement, hospital, health care provider in compliance, circumstances; Payer, reimbursement according to provider contract, medically necessary emergency, urgent care covered under plan; Failure by payer to comply with deadline, health care services subject to review, automatic authorization; Statistics available regarding prior authorization approvals, denials, website; Liberal construction; Rules, regulations

 

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

Georgia Code-Title 33-Chapter 46-Certification of Private Review Agents. Article 2. Prior Authorizations

08/01/2023 Georgia Sections 33-46-23, 33-46-26, 33-46-27, 33-46-28 and 33-46-29

Restrictions on Authorizations When Service Timely Rendered; Timely Notification of Prior Authorization or Adverse Determination; Notification Time for Prior Authorization or Adverse Determination; Honoring of Prior Authorizations; Noncompliance Resulting in Automatic Authorization

Retroactive Denial, State Medical Necessity Decisions-Deadlines
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

Indiana Code-Title 27-Article 1-Chapter 37.5-Health Care Service Prior Authorization

07/12/2023 Indiana Sections 27-1-37.5-1 through 27-1-37.5-14, and 27-1-37.5-17.

Application of Chapter; “Adverse Determination;” “Covered individual;” “CPT Code;” “Health Care Service;” “Health Plan;” “Participating Provider;” “Prior Authorization;” “Urgent Care Situation;” Availability of Prior Authorization Information; Requirements; New Requirements; Address Change; Notices; Request for Prior Authorization; Electronic Transmission; Standardized Form; Response to Request for Prior Authorization; Timing; Incomplete Request; Claim for Which Prior Authorization Was Given; Denial; Resubmission of Claim; Unanticipated, Medically Necessary Health Care Service; Denial; CPT codes exempt from prior authorization; Payment for Health Care Service With Prior Authorization; Contrary Contract Provision Void; Peer to peer review.

Amendments, Retroactive Denial, State Medical Necessity Decisions-Deadlines
State Law

Arkansas Code-Title 23-Subtitle 3-Chapter 99-Subchapter 11. Prior Authorization Transparency Act

07/11/2023 Arkansas Section 23-99-1111

Requests for prior authorization — Qualified persons authorized to review and approve — Adverse determinations to be made only by Arkansas-licensed physicians-— Opportunity to discuss treatment before adverse determination

State Medical Necessity Decisions-Deadlines
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
State Law

Michigan Compiled Laws-Chapter 500. Insurance Code of 1956-Chapter 22. The Insurance Contract

08/12/2022 Michigan Section 2212e

Standard electronic prior authorization transaction process; requirements; adverse determination process; denial and appeals; standard report; modification program; definitions.

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