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

Wyoming Statutes-Title 26-Chapter 55. Ensuring Transparency In Prior Authorization Act

06/27/2024 Wyoming Sections 26-55-101 through 26-55-113

Short title; Definitions; Disclosure and review of prior authorization requirements; Persons qualified to make adverse determinations; Consultation after issuing an adverse determination; Requirements applicable to persons reviewing appeals; Health insurer or contracted utilization review entities’ obligations regarding prior authorization for nonurgent health care services; Health insurer or contracted utilization review entities’ obligations with respect to prior authorizations for urgent health care services; No prior authorization for medications for opioid use disorder; Length of authorization generally; revocation of prior authorizations prohibited; length of authorization for chronic or long-term care conditions; Continuity of care for enrollees; Provider exemptions from prior authorization requirements; Prior authorization for rehabilitative or habilitative services. 

Amendments, Retroactive Denial, State Medical Necessity Appeals-Deadlines
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 422.138

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 13.10.31.2, 13.10.31.7 through 13.10.31.14

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