Certification and member handbook to include utilization review procedures — website or provider portal, prior authorization requirements available on
See bold text below:
1. In the certificate of coverage and the member handbook provided to enrollees, a health carrier shall include a clear and comprehensive description of its utilization review procedures, including the procedures for obtaining review of adverse determinations, and a statement of rights and responsibilities of enrollees with respect to those procedures.
2. A health carrier shall include a summary of its utilization review procedures in material intended for prospective enrollees.
3. A health carrier shall print on its membership cards a toll-free telephone number to call for utilization review decisions.
4. (1) A health carrier or utilization review entity shall make any current prior authorization requirements or restrictions, including written clinical review criteria, readily accessible on its website or provider portal. Requirements and restrictions, including step therapy protocols as such term is defined in section 376.2030, shall be described in detail.
(2) No health carrier or utilization review entity shall amend or implement a new prior authorization requirement or restriction prior to the change being reflected on the carrier or utilization review entity’s website or provider portal as specified in subdivision (1) of this subsection.
(3) Health carriers and utilization review entities shall provide participating providers with written or electronic notice of the new or amended requirement not less than sixty days prior to implementing the requirement or restriction.