MISSISSIPPI LEGISLATURE
2024 Regular Session
To: Public Health and Human Services
By: Representative Zuber
AN ACT TO CREATE THE MISSISSIPPI PRIOR AUTHORIZATION REFORM ACT; TO PROVIDE THE SCOPE OF THE ACT AND DEFINITIONS; TO REQUIRE THE DEPARTMENT OF INSURANCE TO PROMULGATE RULES AND REGULATIONS THAT PROVIDE FOR THE DISCLOSURE AND REVIEW REQUIREMENTS FOR PRIOR AUTHORIZATION; TO PROVIDE THAT IF ANY HEALTH INSURANCE ISSUER REQUIRES PRIOR AUTHORIZATION OF A HEALTH CARE SERVICE, THE INSURER, OR ITS DESIGNEE UTILIZATION REVIEW ORGANIZATION, SHALL, BY JANUARY 1, 2026, MAKE AVAILABLE A STANDARDIZED ELECTRONIC PRIOR AUTHORIZATION REQUEST TRANSACTION PROCESS; TO REQUIRE ALL HEALTH CARE PROFESSIONALS AND PROVIDERS TO USE THE STANDARDIZED ELECTRONIC PRIOR AUTHORIZATION REQUEST TRANSACTION PROCESS BY JANUARY 1, 2028; TO PROVIDE THE TIME FOR EITHER APPROVING OR PROVIDING AN ADVERSE DETERMINATION TO A PRIOR AUTHORIZATION REQUEST IN BOTH NONURGENT AND URGENT SITUATIONS; TO PROVIDE THE PERSONNEL QUALIFIED TO MAKE ADVERSE DETERMINATIONS; TO REQUIRE THE DEPARTMENT OF INSURANCE TO PROMULGATE RULES AND REGULATIONS THAT PROVIDE THE NOTIFICATION REQUIREMENTS TO AN ENROLLEE AND AN ENROLLEE'S HEALTH CARE PROFESSIONAL AND PROVIDER IF A HEALTH INSURANCE ISSUER MAKES AN ADVERSE DETERMINATION; TO PROVIDE THE PERSONNEL WHO ARE QUALIFIED TO REVIEW APPEALS OF ADVERSE DETERMINATIONS; TO REQUIRE A HEALTH INSURANCE ISSUER TO PERIODICALLY REVIEW ITS PRIOR AUTHORIZATION REQUIREMENTS; TO REQUIRE THE DEPARTMENT OF INSURANCE PROMULGATE RULES AND REGULATIONS THAT PROVIDE FOR THE REVOCATION OF PRIOR AUTHORIZATIONS; TO PROVIDE HOW LONG THE LENGTH OF APPROVALS MAY BE FOR PRIOR AUTHORIZATIONS; TO REQUIRE THE DEPARTMENT OF INSURANCE TO PROMULGATE RULES AND REGULATIONS FOR HOW LONG THE APPROVAL OF A PRIOR AUTHORIZATION MAY LAST FOR A CHRONIC CONDITION; TO REQUIRE THE DEPARTMENT OF INSURANCE TO PROMULGATE RULES AND REGULATIONS THAT PROVIDE HOW LONG A HEALTH INSURANCE ISSUER MUST HONOR THE PRIOR AUTHORIZATION GRANTED TO AN ENROLLEE FROM A PREVIOUS HEALTH INSURANCE ISSUER; TO PROVIDE THAT THE FAILURE BY A HEALTH INSURANCE ISSUER TO COMPLY WITH DEADLINES AND OTHER REQUIREMENTS SHALL RESULT IN ANY HEALTH CARE SERVICES SUBJECT TO REVIEW BEING AUTOMATICALLY DEEMED AUTHORIZED BY THE HEALTH INSURANCE ISSUER; TO PROVIDE FOR THE ENFORCEMENT AND ADMINISTRATION OF THIS ACT; TO PROVIDE THE REPORTS THAT MUST BE FILED WITH THE DEPARTMENT OF INSURANCE EACH YEAR; TO AUTHORIZE THE DEPARTMENT OF INSURANCE TO PROMULGATE ANY OTHER RULES AND REGULATIONS AS NECESSARY TO EFFECTUATE THE MISSISSIPPI PRIOR AUTHORIZATION ACT; TO BRING FORWARD SECTIONS 41-83-31 AND 83-9-6.3, MISSISSIPPI CODE OF 1972, FOR THE PURPOSE OF POSSIBLE AMENDMENT; AND FOR RELATED PURPOSES.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MISSISSIPPI:
SECTION 1. This act shall be known and may be cited as the "Mississippi Prior Authorization Reform Act".
SECTION 2. Applicability and scope. This act shall apply to every health insurance issuer and all health benefit plans, as both terms are defined in Section 83-9-6.3, and all private review agents and utilization review plans, as both terms are defined in Section 41-83-1, including employee or employer self-insured health benefit plans under the federal Employee Retirement Income Security Act of 1974, health care provided pursuant to the Workers' Compensation Act and the Mississippi State and School Employees' Life and Health Insurance Plan. This act shall not diminish the duties and responsibilities under other federal or state law or rules promulgated thereunder that are applicable to a health insurer, health insurance issuer, health benefit plan, private review agent, or utilization review plan, including, but not limited to, the requirement of a certificate in accordance with Section 41-83-3.
SECTION 3. Definitions. For the purposes of this act, the following words and phrases shall have the meanings as defined in this section unless the context clearly indicates otherwise:
(a) "Adverse determination" means a determination by a health insurance issuer that, based upon the information provided, a request for a benefit under the health insurance issuer's health benefit plan upon application of any utilization review technique does not meet the health insurance issuer's requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness or is determined to be experimental or investigational and the requested benefit is therefore denied, reduced, or terminated or payment is not provided or made, in whole or in part, for the benefit; the denial, reduction, or termination of or failure to provide or make payment, in whole or in part; or a rescission of coverage determination, which does not include a cancellation or discontinuance of coverage that is attributable to a failure to timely pay required premiums or contributions towards the cost of coverage.
(b) "Appeal" means a formal request, in writing, to reconsider an adverse determination.
(c) "Approval" means a determination by a health insurance issuer that a health care service has been reviewed and, based on the information provided, satisfies the health insurance issuers requirements for medical necessity and appropriateness.
(d) "Clinical review criteria" means the written screening procedures, decision abstracts, clinical protocols, and practice guidelines used by a health insurance issuer to determine the necessity and appropriateness of health care services.
(e) "Department" means the Mississippi Department of Insurance.
(f) "Emergency medical condition" means a medical condition manifesting itself by acute symptoms of sufficient severity, including, but not limited to, severe pain, such that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in: (i) placing the health of the individual or, with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy; (ii) serious impairment to bodily functions; or (iii) serious dysfunction of any bodily organ or part.
(g) "Emergency services" means health care items and services furnished or required to evaluate and treat an emergency medical condition.
(h) "Enrollee" means any person and his or her dependents enrolled in or covered by a health care plan.
(i) "Health care professional" means a physician, a registered professional nurse, or other individual appropriately licensed or registered to provide health care services.
(j) "Health care provider" means any physician, hospital, ambulatory surgery center, or other person or facility that is licensed or otherwise authorized to deliver health care services.
(k) "Health care service" means any services or level of services included in the furnishing to an individual of medical care or the hospitalization incident to the furnishing of such care, as well as the furnishing to any person of any other services for the purpose of preventing, alleviating, curing, or healing human illness or injury, including behavioral health, mental health, home health, and pharmaceutical services and products.
(l) "Health insurance issuer" has the meaning given to that term in Section 83-9-6.3. Any provision of this act that applies to a "health insurance issuer" also applies to any person or entity covered under the scope of this act in Section 3.
(m) "Medically necessary" means a health care professional exercising prudent clinical judgment would provide care to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, disease, or its symptoms and that are: (i) in accordance with professional, evidence-based medicine and generally accepted standards of good medical practice and care; (ii) clinically appropriate in terms of type, frequency, extent, site, and duration and are considered effective for the patient's illness, injury, or disease; and not primarily for the convenience of the patient, treating physician; other health care professional, caregiver, family member, or other interested party, but focused on what is best for the patient's health outcome.
(n) "Physician" means any person with a valid doctor of medicine, doctor of osteopathy or doctor of podiatry degree who is currently and appropriately licensed to practice medicine within the scope of such license.
(o) "Prior authorization" means the process by which a health insurance issuer determines the medical necessity and medical appropriateness of an otherwise covered health care service before the rendering of such health care service. "Prior authorization" includes any health insurance issuer's requirement that an enrollee, health care professional, or health care provider notify the health insurance issuer before or at the time of providing a health care service.
(p) "Urgent health care service" means a health care service with respect to which the application of the time periods for making a nonexpedited prior authorization that in the opinion of a treating health care professional or health care provider with knowledge of the enrollee's medical condition: (i) could seriously jeopardize the life or health of the enrollee or the ability of the enrollee to regain maximum function; or (ii) could subject the enrollee to severe pain that cannot be adequately managed without the care or treatment that is the subject of the utilization review.
(q) "Urgent health care service" does not include emergency services.
(r) "Private review agent" has the meaning given to that term in Section 41-83-1.
SECTION 4. Disclosure and review of prior authorization requirements. The department shall promulgate rules and regulations that provide for the disclosure and review requirements for prior authorizations. Such rules and regulations shall require a health insurance issuer to comply with at least the following requirements:
(a) Maintain a complete list of services for which prior authorization is required, including for all services where prior authorization is performed by an entity under contract with the health insurance issuer.
(b) Make any current prior authorization requirements and restrictions for health care services other than pharmaceutical services and products, including the written clinical review criteria, readily accessible, described in detail, written in easily understandable language and conspicuously posted on its website to enrollees, health care professionals, and health care providers. Content published by a third party and licensed for use by a health insurance issuer may be made available through the health insurance issuers secure, password protected website so long as the access requirements of the website do not unreasonably restrict access.
(c) Provide the following information on the website for each health care service other than pharmaceutical services and products that is subject to prior authorization:
(i) When prior authorization became required for policies issued or health benefit plan documents delivered in Mississippi, including the effective date or dates and the termination date or dates, if applicable, in Mississippi;
(ii) The date the Mississippi-specific requirement was listed on the health insurance issuer's, health benefit plan's, or private review agent's website;
(iii) Where applicable, the date that prior authorization was removed for Mississippi; and
(iv) Where applicable, access to a standardized electronic prior authorization request transaction process.
(d) Establish the clinical review criteria based on the following factors:
(i) Generally accepted standards except where state law provides its own standard;
(ii) Quality of care and access to needed health care services;
(iii) Evidence-based;
(iv) Sufficiently flexible to allow deviations from norms when justified on a case-by-case basis; and
(v) Evaluated and updated as provided in the rules and regulations established by the department, but such time frame shall not be less than annually.
(e) Not deny a claim for failure to obtain prior authorization if the prior authorization requirement was not in effect on the date of service on the claim.
(f) When either implementing a new prior authorization requirement for health care services other than pharmaceutical services and products, or restricting or amending an existing requirement or restriction for health care services other than pharmaceutical services and products, provide the contracted health care professionals and contracted health care providers of enrollees notice of the new or amended requirement or amendment no less than sixty (60) days before the requirement or restriction is implemented. Such notice requirement may be met if the health insurance issuer posts the notice on its website. The health insurance issuer shall ensure that the new or amended requirement is not implemented unless the health insurance issuer's website has been updated to reflect the new or amended requirement or restriction.
(g) Make statistics available regarding prior authorization approvals and denials on their website in a readily accessible format. The statistics must be updated annually and include all of the following information:
(i) A list of all health care services other than pharmaceutical services and products that are subject to prior authorization;
(ii) The total number of prior authorization requests received;
(iii) The number of prior authorization requests denied during the previous plan year by the health insurance issuer, health benefit plan, or private review agent with respect to each service described in paragraph (i) and the top five (5) reasons for denial;
(iv) The number of requests described in paragraph (iii) that were appealed, the number of the appealed requests that upheld the adverse determination, and the number of appealed requests that reversed the adverse determination;
(v) The average time between submission and response; and
(vi) Any other information, including any information related to pharmaceutical services and products, as the department determines appropriate.
SECTION 5. Standardized electronic prior authorizations. (1) If any health insurance issuer requires prior authorization of a health care service, the insurer, or its designee utilization review organization, shall, by January 1, 2026, make available a standardized electronic prior authorization request transaction process using an Internet webpage, Internet webpage portal, or similar electronic, Internet, and web-based system.
(2) After January 1, 2026, any health insurance issuer that receives a prior authorization request from a health care professional or health care provider who does not submit the prior authorization request with the standardized electronic prior authorization request transaction process created in paragraph (a) of this section shall not be subject to the timelines put in place by the department as provided in this act and shall not be subject to the fines provided in this act.
(3) By January 1, 2028, all health care professionals and health care providers shall be required to use the standardized electronic prior authorization request transaction process created in paragraph (a) of this section.
(4) (a) The department shall promulgate rules and regulations as necessary to effectuate the provisions of this section.
(b) The department shall also promulgate rules and regulations regarding any written notice or other form or document that the department determines shall be in writing.
SECTION 6. Prior authorizations in nonurgent circumstances. Notwithstanding any other provision of law, if a health insurance issuer requires prior authorization of a health care service, the health insurance issuer must make an approval or adverse determination and notify the enrollee, the enrollee's health care professional, and the enrollee's health care provider of the approval or adverse determination as provided in rules and regulations promulgated by the department, but no later than five (5) calendar days after obtaining all necessary information to make the approval or adverse determination.
As used in this section, "necessary information" includes the results of any face-to-face clinical evaluation, second opinion, or other clinical information that is directly applicable to the requested service that may be required.
SECTION 7. Prior authorizations in urgent circumstances.
(1) If requested by a treating health care provider or health care professional for an enrollee, and notwithstanding any other provision of law, a health insurance issuer must render an approval or adverse determination concerning urgent care services and notify the enrollee, the enrollee's health care professional, and the enrollee's health care provider of that approval or adverse determination as provided in rules and regulations promulgated by the department, but not later than forty-eight (48) hours after receiving all information needed to complete the review of the requested health care services, which shall include an explanation on what makes the prior authorization request urgent.
(2) To facilitate a prior authorization determination as provided in this section, a health insurance issuer must establish a mechanism to ensure health care professionals have access to appropriately trained and licensed clinical personnel who have access to physicians for consultation, designated by the plan to make such determinations for prior authorization concerning urgent care services.
SECTION 8. Personnel qualified to make adverse determinations. (1) A health insurance issuer must ensure that all adverse determinations are made by a physician when the request is by a physician or a representative of a physician. The physician must:
(a) Possess a current and valid nonrestricted license in any United States jurisdiction; and
(b) Any other qualifications deemed necessary by rules and regulations promulgated by the department.
(2) Notwithstanding the foregoing, the health insurance issuer must also comply with Section 41-83-31 requiring concurrence in the adverse determination by a physician licensed to practice in Mississippi.
SECTION 9. Notifications for adverse determinations. The department shall promulgate rules and regulations that provide the notification requirements to an enrollee, the enrollee's health care professional, and the enrollee's health care provider if a health insurance issuer makes an adverse determination. Such notification requirements shall include at least the following:
(a) The reasons for the adverse determination and related evidence-based criteria, including a description of any missing or insufficient documentation;
(b) The right to appeal the adverse determination;
(c) Instructions on how to file the appeal; and
(d) Additional documentation necessary to support the appeal as provided by the department.
SECTION 10. Personnel qualified to review appeals of adverse determinations. (1) A health insurance issuer shall ensure that all appeals of an adverse determination for a health care service other than pharmaceutical services or products are reviewed by a physician, and all appeals of an adverse determination for a pharmaceutical service or product are reviewed by a pharmacist, when the request is by a physician or a representative of a physician. The department shall issue rules and regulations on the qualifications of the physician or pharmacist. Such rules and regulations shall at least require the physician or pharmacist to have the following qualifications:
(a) Possess a current and valid nonrestricted license to practice medicine by the Mississippi State Board of Medical Licensure;
(b) Be certified by the Board(s) of the American Board of Medical Specialists or the American Board of Osteopathy within the relevant specialty of a physician who typically manages the medical condition or disease;
(c) Be knowledgeable of, and have experience providing, the health care services under appeal;
(d) Not have been directly involved in making the adverse determination; and
(e) Consider all known clinical aspects of the health care service under review, including, but not limited to, a review of all pertinent medical records provided to the health insurance issuer by the enrollee's health care professional or health care provider and any medical literature provided to the health insurance issuer by the health care professional or health care provider.
(2) Notwithstanding the foregoing, a licensed health care professional who satisfies the requirements in this section may review appeal requests submitted by a health care professional licensed in the same profession.
SECTION 11. Insurer review of prior authorization requirements. A health insurance issuer shall periodically review its prior authorization requirements and consider removal of prior authorization requirements as provided by the department in its rules and regulations.
SECTION 12. Revocation of prior authorizations. (1) The department shall promulgate rules and regulations providing for the revocation of prior authorizations. Such rules and regulations shall include at least the following:
(a) A health insurance issuer may not revoke or further limit, condition, or restrict a previously issued prior authorization approval while it remains valid under this act.
(b) Notwithstanding any other provision of law, if a claim is properly coded and submitted timely to a health insurance issuer, the health insurance issuer shall make payment according to the terms of coverage on claims for health care services for which prior authorization was required and approval received before the rendering of health care services, unless one of the following occurs:
(i) It is timely determined that the enrollee's health care professional or health care provider knowingly provided health care services that required prior authorization from the health insurance issuer or its contracted private review agent without first obtaining prior authorization for those health care services;
(ii) It is timely determined that the health care services claimed were not performed;
(iii) It is timely determined that the enrollee receiving such health care services was not an enrollee of the health care plan; or
(iv) The approval was based upon a material misrepresentation by the enrollee, health care professional, or health care provider; as used in this subparagraph, "material" means a fact or situation that is not merely technical in nature and results or could result in a substantial change in the situation.
(2) Nothing in this section shall preclude a private review agent or a health insurance issuer from performing post-service reviews of health care claims for purposes of payment integrity or for the prevention of fraud, waste, or abuse.
SECTION 13. Length of approvals. The department shall promulgate rules and regulations that provide how long a prior authorization approval shall be valid. Any chemotherapy treatment for any type of cancer, when subject to a prior authorization, shall be valid for the entirety of the treatment plan as determined by the treating health care provider or health care professional, regardless of the payer. The department shall provide that the approval period shall be effective regardless of any changes, including any changes in dosage for a prescription drug prescribed by the health care professional; however, all dosage increases must be based on established evidentiary standards. Nothing in this section shall prohibit a health insurance issuer from having safety edits in place. The provisions of this section shall not apply to the prescription of benzodiazepines or Schedule II narcotic drugs, such as opioids. Nothing in this section shall require a policy or plan to cover any pharmaceutical service or product that is not FDA approved or any care, treatment, or services for any health condition that the terms of coverage otherwise completely exclude from the policy's or plan's covered benefits without regard for whether the care, treatment, or services are medically necessary.
SECTION 14. Approvals for chronic conditions. If a health insurance issuer requires a prior authorization for a recurring health care service or maintenance medication for the treatment of a chronic or long-term condition, the department shall promulgate rules and regulations that provide how long that prior approval shall remain valid. This section shall not apply to the prescription of benzodiazepines or Schedule II narcotic drugs, such as opioids. Nothing in this section shall require a policy to cover any pharmaceutical service or product that is not FDA approved or any care, treatment, or services for any health condition that the terms of coverage otherwise completely exclude from the policy's covered benefits without regard for whether the care, treatment, or services are medically necessary.
SECTION 15. Continuity of prior approvals. (1) When a new health insurance issuer receives information documenting a prior authorization approval from the enrollee or from the enrollee's health care professional or health care provider, the department shall promulgate rules and regulations that provide how long a health insurance issuer must honor the prior authorization granted to an enrollee from a previous health insurance issuer; however, such period of time shall not be less than ninety (90) days.
(2) The department shall promulgate rules and regulations that authorize the health insurance issuer to perform its own review to determine whether to continue the prior authorization approval, and how the enrollee shall be affected if there is a change in coverage or approval criteria.
(3) Except to the extent required by medical exceptions processes for prescription drugs, nothing in this section shall require a policy to cover any care, treatment, or services for any health condition that the terms of coverage otherwise completely exclude from the policy's covered benefits without regard for whether the care, treatment, or services are medically necessary.
SECTION 16. Effect of insurer's failure to comply. A failure by a health insurance issuer to comply with the deadlines and other requirements specified in this act shall result in any health care services subject to review to be automatically deemed authorized by the health insurance issuer or its contracted private review agent.
SECTION 17. Enforcement and administration. (1) In addition to the enforcement powers granted to it by law to enforce the provisions of this act, the department shall be authorized to require a private review agent or health insurance issuer to submit a plan of correction for violations of this act, or both. Subject to regulations promulgated by the department, the department may impose upon a private review agent, health benefit plan or health insurance issuer an administrative fine not to exceed Ten Thousand Dollars ($10,000.00) per violation for failure to submit a requested plan of correction, failure to comply with its plan of correction, or repeated violations of this act. The department may also exercise all authority granted to it pursuant to Section 41-83-13 to deny or revoke a certificate of a private review agent for a violation of this act.
(2) Any person or his or her treating physician who believes that his or her treating insurance issuer or health benefit plan is in violation of the provisions of this act may file a complaint with the department. The department shall review all complaints received and investigate all complaints that it deems necessary to state a potential violation. The department shall fairly, efficiently, and timely review and investigate complaints. Health insurance issuers, health benefit plans, and private review agents found to be in violation of this act shall be penalized in accordance with this section.
(3) The department shall promulgate rules and regulations that require a health care provider or health care professional to submit a plan of correction for fraud, waste or abuse in violation of this act. Subject to regulations that the department shall promulgate, the department may impose upon a health care provider or health care professional an administrative fine not to exceed Ten Thousand Dollars ($10,000.00) per violation for failure to submit a requested plan of correction, failure to comply with its plan of correction, or repeated violations of this act.
(4) Any person or his or her health insurance issuer, health benefit plan or private review agent who believes that his or her health care provider or health care professional is committing fraud, waste or abuse in violation of this act may file a complaint with the department. The department shall review all complaints received and investigate all complaints that it deems necessary to state a potential violation. The department shall fairly, efficiently, and timely review and investigate complaints. Health care providers or health care professionals found to be in violation of this act shall be penalized in accordance with this section.
(5) The department shall promulgate rules and regulations to govern the administration of this section.
SECTION 18. Reports to the department. (1) By June 1, 2026, and each June 1 after that date, a health insurance issuer shall report to the department, on a form issued by the department, the following aggregated trend data related to the insurer's prior authorization practices and experience for the prior plan year:
(a) The number of prior authorization requests.
(b) The number of prior authorization requests denied.
(c) The number of appeals received.
(d) The number of adverse determinations reversed on appeal.
(e) Of the total number of prior authorization requests, the number of prior authorization requests that were not submitted electronically.
(f) The ten (10) services that were most frequently denied.
(g) The ten (10) reasons prior authorization requests were most frequently denied.
(h) When legally permissible, the health care providers and health care professionals who were issued a final determination or adjudication of fraud, waste or abuse.
(2) All reports required by this section shall be considered public records pursuant to the Mississippi Public Records Act of 1983, and the department shall make all reports freely available to requestors and post all reports to its public website without redactions.
SECTION 19. The department shall promulgate rules and regulations that provide for the following:
(a) Creating a period of time for prior authorization on inpatient stays at the hospitals that allows for the hospital to access the correct insurance information of the patient. Such time shall not be less than forty-eight (48) hours but not more than five (5) days.
(b) Create a period of time for the re-authorization of a change of procedure code where the health care provider or health care professional was forced to make a change to the health care service due to medical necessity that the prior authorization was issued for and did not have sufficient time to request a new prior authorization before the health care service had to be performed. Such period of time shall not be more than fourteen (14) days.
(c) Require an approved prior authorization form from a third-party provider to contain at least the following information when the form is returned to the enrollee, the enrollee's health care professional and the enrollee's health care provider:
(i) The specific type of facility approved;
(ii) The specific facility approved; and
(iii) Whether the approval was for inpatient or outpatient services.
SECTION 20. (1) The department shall promulgate any other rules and regulations as necessary to effectuate the provisions of this act. All rules and regulations shall be promulgated pursuant to the Mississippi Administrative Procedures Act. Such rules and regulations shall be promulgated not later than July 1, 2025.
(2) To the extent that any provision contained in this act may conflict with any such applicable provision of law, regulation or directive from the Centers for Medicare and Medicaid Services with respect to the Division of Medicaid, the law, regulation or directive from the Centers for Medicare and Medicaid Services shall control. The Mississippi Division of Medicaid shall provide notice to the Department of Insurance to any potential conflict, and the Department of Insurance shall waive the conflicting requirement created under this act. The Department of Insurance shall notify the Chairmen of the House and Senate Insurance Committees of any such waiver and provide public notice of the waiver by posting the notice on their website. The Department of Insurance shall promulgate any rules and regulations as necessary on the implementation of the waiver process provided in this subsection.
SECTION 21. Section 41-83-31, Mississippi Code of 1972, is brought forward as follows:
41-83-31. Any program of utilization review with regard to hospital, medical or other health care services provided in this state shall comply with the following:
(a) No determination adverse to a patient or to any affected health care provider shall be made on any question relating to the necessity or justification for any form of hospital, medical or other health care services without prior evaluation and concurrence in the adverse determination by a physician licensed to practice in Mississippi. The physician who made the adverse determination shall discuss the reasons for any adverse determination with the affected health care provider, if the provider so requests. The physician shall comply with this request within fourteen (14) calendar days of being notified of a request. Adverse determination by a physician shall not be grounds for any disciplinary action against the physician by the State Board of Medical Licensure.
(b) Any determination regarding hospital, medical or other health care services rendered or to be rendered to a patient which may result in a denial of third-party reimbursement or a denial of precertification for that service shall include the evaluation, findings and concurrence of a physician trained in the relevant specialty or subspecialty, if requested by the patient's physician, to make a final determination that care rendered or to be rendered was, is, or may be medically inappropriate.
(c) The requirement in this section that the physician who makes the evaluation and concurrence in the adverse determination must be licensed to practice in Mississippi shall not apply to the Comprehensive Health Insurance Risk Pool Association or its policyholders and shall not apply to any utilization review company which reviews fewer than ten (10) persons residing in the State of Mississippi.
SECTION 22. Section 83-9-6.3, Mississippi Code of 1972, is brought forward as follows:
83-9-6.3. (1) As used in this section:
(a) "Health benefit plan" means services consisting of medical care, provided directly, through insurance or reimbursement, or otherwise, and including items and services paid for as medical care under any hospital or medical service policy or certificate, hospital or medical service plan contract, preferred provider organization, or health maintenance organization contract offered by a health insurance issuer. The term "health benefit plan" includes the Medicaid fee-for-service program and any managed care program, coordinated care program, coordinated care organization program or health maintenance organization program implemented by the Division of Medicaid.
(b) "Health insurance issuer" means any entity that offers health insurance coverage through a health benefit plan, policy, or certificate of insurance subject to state law that regulates the business of insurance. "Health insurance issuer" also includes a health maintenance organization, as defined and regulated under Section 83-41-301 et seq., and includes the Division of Medicaid for the services provided by fee-for-service and through any managed care program, coordinated care program, coordinated care organization program or health maintenance organization program implemented by the division.
(c) "Prior authorization" means a utilization management criterion used to seek permission or waiver of a drug to be covered under a health benefit plan that provides prescription drug benefits.
(d) "Prior authorization form" means a standardized, uniform application developed by a health insurance issuer for the purpose of obtaining prior authorization.
(2) Notwithstanding any other provision of law to the contrary, in order to establish uniformity in the submission of prior authorization forms, on or after January 1, 2014, a health insurance issuer shall use only a single, standardized prior authorization form for obtaining any prior authorization for prescription drug benefits. The form shall not exceed two (2) pages in length, excluding any instructions or guiding documentation. The form shall also be made available electronically, and the prescribing provider may submit the completed form electronically to the health benefit plan. Additionally, the health insurance issuer shall submit its prior authorization forms to the Mississippi Department of Insurance to be kept on file on or after January 1, 2014. A copy of any subsequent replacements or modifications of a health insurance issuer's prior authorization form shall be filed with the Mississippi Department of Insurance within fifteen (15) days prior to use or implementation of such replacements or modifications.
(3) A health insurance issuer shall respond within two (2) business days upon receipt of a completed prior authorization request from a prescribing provider that was submitted using the standardized prior authorization form required by subsection (2) of this section.
SECTION 23. This act shall take effect and be in force from and after July 1, 2024.