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 422.138

Prior authorization

Retroactive Denial
State Law

Pennsylvania Consolidated Statutes-Title 40-Insurance-Chapter 38. Retroactive Denial of Reimbursements

08/21/2023 Pennsylvania Sections 3801-3806

Scope of chapter; Definitions; Retroactive denial of reimbursement; Exceptions to retroactive denial of reimbursement; Coordination of benefits; Tolling.

Retroactive Denial
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

Iowa Code-Title XIII-Chapter 514F. Utilization and Cost Control

08/04/2023 Iowa Section 514F.8

Prior authorizations —— reimbursement.

Retroactive Denial
State Law

New Mexico Admin. Code-Title 13-Chapter 10-Part 31. Prior Authorization

10/04/2021 New Mexico Sections, through

Scope; Definitions; General Requirements; Prior Authorization Submission; Documentation and Transparency; Auto-Adjudication; Reserved; Penalties; Severability

Amendments, Retroactive Denial
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

Oregon Admin. Rules-Insurance Regulation-Chapter 836-Division 53. Health Benefit Plans

08/20/2023 Oregon Section 836-053-1203

Prior Authorization Trade Practices for Health Insurance other than Health Benefit plans

Retroactive Denial
State Law

Dept. of Prof. & Fin. Regulation-Chapter 850-Health Plan Accountability

08/07/2023 Maine Sections 1-10

Purpose; Authority; Applicability and Scope; Affordable Care Act; Definitions; Quality Assurance Standards; Access to Services; Adverse Health Care Treatment Decisions; Grievance Register and Grievance Procedures; Reporting Requirements; Effective Date

Credentialing-Deadlines, Credentialing-Due Process-Denial of Contract, Network Adequacy, Retroactive Denial, State Medical Necessity Appeals-Deadlines, State Medical Necessity Decisions-Deadlines, U.R. Criteria