Guidelines for Prior Authorization Forms

 

DEPARTMENT OF FINANCIAL SERVICES

OIR – Insurance Regulation

RULE NO.:RULE TITLE:

69O-161.010Guidelines for Prior Authorization Forms

NOTICE OF CHANGE

Notice is hereby given that the following changes have been made to the proposed rule in accordance with subparagraph 120.54(3)(d)1., F.S., published in Vol. 42 No. 190, September 29, 2016 issue of the Florida Administrative Register.

Rule 69O-161.010 is changed to read:

(1) No change.

(2) Definitions: As used in this Rule:

(a) “Health Insurer” issuer means an authorized insurer offering health insurance as defined in s. 624.603, F.S., a managed care plan as defined in s. 409.962(9), F.S., or a health maintenance organization as defined in s. 641.19(12) F.S.

(b) “Utilization review entity” means any person that performs prior authorization for a health insurer issuer.

(c) No change.

(d) “Prior authorization” means any practice implemented by a health insurer or a health insurer’s utilization review entity in which coverage of a health care service, device, or drug is dependent upon a covered person or health care practitioner obtaining approval from the health insurer issuer or utilization review entity prior to the service, device, or drug being performed, received, or prescribed, as applicable. “Prior authorization” includes prospective or utilization review procedures conducted prior to providing a health care service, device, or drug.

(3) All prior authorization forms must provide for the following information:

(a) through (g) No change.

(h) All services tried and failed, or shown to be ineffective.

(i) A list of any additional documentation required by the health insurer issurer or utilization review entity to complete its review of the prior authorization request, and any other information necessary to facilitate the determination of the medical necessity of the requested procedure, course of treatment or prescription drug benefit.

(j) through (l) No change.

(m) Any other information required to determine or facilitate the determination of the medical necessity of the requested medical procedure, course of treatment, or prescription drug benefit.

(4) All prior authorization forms must contain information where a provider may find a health insurer’s insurance issuer’s step therapy or fail first protocol requirements and quantity limits for all list of services subject to prior authorization.

(5) The prior authorization form must contain the direct contact information for the health insurer utilization review entity.

(6) No Change

(7) Disclosure and review of prior authorization requirements.

(a) A health insurer utilization review entity or issuer shall make any current prior authorization requirements, restrictions and forms, directions as to when to use such forms, and instructions for filling out such forms, readily accessible on its website and in written or electronic form upon request for beneficiaries and health care providers, and the general public. Requirements shall be described in detail but also in clear, easily-understandable language. Clinical criteria shall be described in language easily understandable by a health care provider.

(b) If a utilization review entity or issuer intends either to implement a new prior authorization requirement or restriction, or amend an existing requirement or restriction, the utilization review entity shall ensure that the new or amended requirement is not implemented unless the utilization review entity’s website has been updated to reflect the new or amended requirement or restriction. This shall not extend to expansion of coverage for new health care services.

(c) If a utilization review entity or issuer intends either to implement a new prior authorization requirement or restriction, or amend an existing requirement or restriction, the utilization review entity shall provide beneficiaries who are currently using the affected health care service and all contracted health care physicians who provide affected health care service or services of written notice of the new or amended requirement or amendment no less than 60 days before the requirement or restriction is implemented. Such notice may be delivered electronically or by other means as agreed to by the receiving entity.