Changes to Existing Law
SB87 — Address preauthorization requirements for certain health care services and utilization review requirements for certain health benefit plans.
1 section modified+157-0
View:
§ 58-17
New Section+157
NEW SECTION added to Chapter 58-17
H: Before an adverse determination is issued by a utilization review organization that questions the medical necessity, appropriateness, or experimental or investigational nature of a health care service, the organization shall provide to the health care practitioner who ordered, requested, provided, or is to provide the service, a reasonable opportunity to discuss the patient's treatment plan and the clinical basis for the organization's determination with a physician or an advanced practice professional. If the service was ordered, requested, provided, or is to be provided by a physician, the opportunity to discuss the treatment plan and the clinical basis must be with another physician who is licensed to practice medicine in this state and has the same or a similar specialty. 33 This section applies only to a utilization review requested on or after July 1, 2025. A utilization review requested before July 1, 2025, is governed by the law as it existed immediately before July 1, 2025.