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
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

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

Illinois Compiled Statutes-215 ILCS 200. Prior Authorization Reform Act.

08/03/2023 Illinois Sections 1 through 85

See the text for the various section titles.

Amendments, Medical Necessity-Definition, Retroactive Denial, 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 33-46-2 through 33-46-4

Application; Legislative Purposes and Intent; Definitions

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

Pennsylvania Admin. Code-Title 31-Part X-Chapter 301-Health Maintenance Organization

08/22/2023 Pennsylvania Section 301.2

Definitions

Medical Necessity-Definition
State Law

Oklahoma Statutes-Title 36. Insurance

08/18/2023 Oklahoma Section 6592

Definitions

Medical Necessity-Definition
State Law

Nebraska Rev. Statutes-Chapter 44-Insurance (Out-of-Network Emergency Medical Care Act)

08/10/2023 Nebraska Sections 44-6834 through 44-6846

Act, how cited; Definitions, where found;Covered person, defined;Emergency medical condition, defined;Emergency services, defined;Health benefits plan, defined; Health care facility, defined; Health care professional, defined; Health care provider, defined; Insurer, defined; Medical assistance program, defined; Medically necessary, defined;  TRICARE, defined

Medical Necessity-Definition, OON-Payment Issues
State Law

North Dakota Admin. Code-Title 45-Article 45-06-Chapter 45-06-07. Model Reg. to Implement Rules Regarding Contracts and Services of HMOs

08/13/2023 North Dakota Section 45-06-07-03

Definitions

Medical Necessity-Definition
State Law

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

08/26/2023 Washington Section 48.43.400

Prescription drug utilization management — Definitions

Medical Necessity-Definition, U.R. Criteria