Pursuant to the rules of the Department of State, including Rule 1S-1.002(8)(a)1., F.A.C., the Financial Services Commission hereby summarizes the proposed action to Rule 69O-161.001,.009,.010,.011: Prior Authorization Forms: The rules adopt a ...

 

DEPARTMENT OF FINANCIAL SERVICES

OIR – Insurance Regulation

RULE NOS.:RULE TITLES:

69O-161.001Purpose

69O-161.009Form Availability

69O-161.010Guidelines for Prior Authorization Forms

69O-161.011Use of Prior Authorization Form

PURPOSE AND EFFECT: Pursuant to the rules of the Department of State, including Rule 1S-1.002(8)(a)1., F.A.C., the Financial Services Commission hereby summarizes the proposed action to Rule 69O-161.001,.009,.010,.011: Prior Authorization Forms: The rules adopt a standard prior authorization form and guidelines for all prior authorization forms.

SUMMARY: The statute requires the FSC to adopt the form and guidelines in consultation with the Agency for Health Care Administration. Improves the position of the Office in implementing the statutory mandate.

SUMMARY OF STATEMENT OF ESTIMATED REGULATORY COSTS AND LEGISLATIVE RATIFICATION: The Agency has determined that this will not have an adverse impact on small business or likely increase directly or indirectly regulatory costs in excess of $200,000 in the aggregate within one year after the implementation of the rule. A SERC has not been prepared by the Agency.

The Agency has determined that the proposed rule is not expected to require legislative ratification based on the statement of estimated regulatory costs or if no SERC is required, the information expressly relied upon and described herein: : Agency personnel familiar with the subject matter of the rule amendment have performed an economic analysis of the rule amendment that shows that the rule amendment is unlikely to have an adverse impact on the State economy in excess of the criteria established in Section 120.541(2)(a), Florida Statutes.

Any person who wishes to provide information regarding a statement of estimated regulatory costs, or provide a proposal for a lower cost regulatory alternative must do so in writing within 21 days of this notice.

RULEMAKING AUTHORITY: 624.308(1), 627.647, 627.42392, FS.

LAW IMPLEMENTED: 624.307(1), 627.510(2), 627.647, 627.42392, FS.

IF REQUESTED WITHIN 21 DAYS OF THE DATE OF THIS NOTICE, A HEARING WILL BE HELD AT THE DATE,TIME AND PLACE SHOWN BELOW(IF NOT REQUESTED, THIS HEARING WILL NOT BE HELD):

DATE AND TIME: Thursday, October 27, 2016, 2:00 p.m.

PLACE: 116 Larson Building, 200 East Gaines Street, Tallahassee, Florida

Pursuant to the provisions of the Americans with Disabilities Act, any person requiring special accommodations to participate in this workshop/meeting is asked to advise the agency at least 5 days before the workshop/meeting by contacting: Shannon Doheny, Office of Insurance Regulation, E-mail [e-mail].. If you are hearing or speech impaired, please contact the agency using the Florida Relay Service, 1(800)955-8771 (TDD) or 1(800)955-8770 (Voice).

THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE IS: Shannon Doheny, Office of Insurance Regulation, E-mail [e-mail]

 

THE FULL TEXT OF THE PROPOSED RULE IS:

69O-161.001 Purpose

The purpose of this chapter is to establish uniform claim forms for claims relating to health insurance and industrial life insurance policies, to establish guidelines for all prior authorization forms which ensure the general uniformity of such forms, and to adopt a prior authorization form for use by health insurance issuers which do not provide an electronic prior authorization process for use by its contracted providers.

Rulemaking Specific Authority 624.308(1), 627.647 FS. Law Implemented 624.307(1), 627.510(2), 627.647 FS. History–New 4-25-88, Formerly 4-74.001, Amended 6-8-94, Formerly 4-161.00, Amended _____________.

 

69O-161.009 Form Availability.

All forms referenced in this rule chapter may be obtained at www.floir.com by writing to: Office of Insurance Regulation, Bureau of Life and Health Forms, Rates and Reserve Analysis, Larson Building, Tallahassee, Florida 32399-0328.

Rulemaking Specific Authority 624.308(1), 627.647 FS. Law Implemented 624.307(1), 627.510(2), 627.647 FS. History–New 6-8-94, Formerly 4-161.009, Amended_____________.

 

69O-161.010 Guidelines for Prior Authorization Forms

(1) Scope: This rule applies to all insurance companies, health maintenance organizations, and managed care entities authorized to write health insurance in Florida.

(2) Definitions: As used in this rule:

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

b. “Utilization review entity” means any person that performs prior authorization for an issuer.

c. “Person” has the same meaning as defined in Section 624.04, F.S.

d. “Prior authorization” means any practice implemented by an issuer or 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 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. Sufficient information to identify the covered person, including the covered person’s date of birth, full name, and health plan identification number.

b. Sufficient information to identify the ordering provider, including the provider’s name, National Provider Identification number, and the provider’s contact information.

c. Sufficient information to identify the rendering provider, including the name of the rendering provider, provider group, or facility, corresponding National Provider Identification number, and the rendering provider’s contact information.

d. Sufficient information to identify and contact the rendering facility, if different from c.

e. Where the service or procedure will be performed, if different from c. or d.

f. The health care service being requested, including the medical reason therefore.

g. The unit or volume of the procedure, service, or device being requested when applicable.

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

i. A list of any additional documentation required by the issuer or utilization review entity to complete its review of the prior authorization request.

j. The priority of the prior authorization request. At a minimum, the prior authorization form shall contain the following designations:

i. Standard.

ii. Date of Service, which should include a space for the planned date of a service.

iii. Urgent or Emergency, to be used when the provider certifies that applying the standard review time frame may seriously jeopardize the life or health of the patient.

k. The latest International Classification of Disease primary diagnosis code.

l. An attestation or certification that all information provided is true and accurate.

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 insurance issuer’s step therapy or fail first protocol requirements and quantity limits for all services subject to prior authorization.

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

(6) The prior authorization form may not require information that is not needed to make a determination or facilitate a determination of medical necessity of the requested medical procedure, course of treatment, or prescription drug benefit.

(7) Disclosure and review of prior authorization requirements.

(a) A utilization review entity or issuer shall make any current prior authorization requirements, restrictions and forms readily accessible on its website and in written or electronic form upon request for beneficiaries, 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.

Rulemaking Authority 624.308(1), 627.42392 FS. Law Implemented 624.307(1), 627.42392 FS. History–New ___________.

 

69O-161.011 Use of Prior Authorization Form

All authorized insurers offering health insurance as defined in Section 624.603, F.S., managed care plans as defined in Section 409.962(9), F.S., and health maintenance organizations as defined in Section 641.19(12), F.S., which do not provide an electronic prior authorization process for use by its contracted providers shall use only the Prior Authorization Form (OIR Form OIR-B2-2180) (**/**) which is hereby incorporated and made part of this rule chapter by reference.

Rulemaking Authority 624.308(1), 627.42392 FS. Law Implemented 624.307(1), 627.42392, FS. History–New __________.

 

NAME OF PERSON ORIGINATING PROPOSED RULE: Shannon Doheny, Office of Insurance Regulation, E-mail: [e-mail]

NAME OF AGENCY HEAD WHO APPROVED THE PROPOSED RULE: THE FINANCIAL SERVICES COMMISSION

DATE PROPOSED RULE APPROVED BY AGENCY HEAD: September 20, 2016

DATE NOTICE OF PROPOSED RULE DEVELOPMENT PUBLISHED IN FAR: July 8, 2016