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) “Health Insurer” 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 a health insurer.

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

(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 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 subparagraph c.

(e) Where the service or procedure will be performed if different from subparagraph 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 and shown to be ineffective.

(i) A list of any additional documentation required by the health insurer 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) The priority of the prior authorization request. At a minimum, the prior authorization form shall contain the following designations:

1. Standard.

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

3. 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.

(4) All prior authorization forms must contain information where a provider may find a health insurer’s list of services subject to prior authorization.

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

(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 health insurer shall make any current prior authorization forms, directions as to when to use such forms, and instructions for filling out such forms, readily accessible on its website and in written form upon request for beneficiaries and health care providers.

Rulemaking Authority 624.308(1), 627.42392 FS. Law Implemented 624.307(1), 627.42392 FS. History–New 1-11-17.