Vermont § 9418b - Prior authorization

§ 9418b. Prior authorization

• (a) Health plans shall pay claims for health care services for which prior authorization
  was required by and received from the health plan, unless: (1) the insured was not a covered individual at the time the service was rendered; (2) the insured’s benefit limitations were exhausted; (3) the prior authorization was based on materially inaccurate information from the health
  care provider; (4) the health plan has a reasonable belief that fraud or other intentional misconduct
  has occurred; or (5) the health plan determines through coordination of benefits that another health insurer
  is liable for the claim. (b) Notwithstanding the provisions of subsection (a) of this section, nothing in this
  section shall be construed to prohibit a health plan from denying continued or extended
  coverage as part of concurrent review, denying a claim if the health plan is not primarily
  obligated to pay the claim, or applying payment policies that are consistent with
  an applicable law, rule, or regulation. (c)(1)(A) Except as provided in subdivision (B) of this subdivision (1), a health plan shall
  not impose any prior authorization requirement for any admission, item, service, treatment,
  or procedure ordered by a primary care provider. (B) The prohibition set forth in subdivision (A) of this subdivision (1) shall not be
  construed to prohibit prior authorization requirements for prescription drugs or for
  an admission, item, service, treatment, or procedure that is provided out-of-network. (2) As used in this subsection, “primary care provider” means a health care provider who
  is contracted and enrolled with the health plan as a primary care provider. (d)(1) A health plan shall furnish, upon request from a health care provider, a current list
  of services and supplies requiring prior authorization. (2) A health plan shall make a current list of services and supplies requiring prior authorization
  available to the public on the insurer’s website. (e) In addition to any other remedy provided by law, if the Commissioner finds that a
  health plan has engaged in a pattern and practice of violating this section, the Commissioner
  may impose an administrative penalty against the health plan of no more than $500.00
  for each violation and may order the health plan to cease and desist from further
  violations and order the health plan to remediate the violation. In determining the
  amount of penalty to be assessed, the Commissioner shall consider the following factors: (1) the appropriateness of the penalty with respect to the financial resources and good
  faith of the health plan; (2) the gravity of the violation or practice; (3) the history of previous violations or practices of a similar nature; (4) the economic benefit derived by the health plan and the economic impact on the health
  care facility or health care provider resulting from the violation; and (5) any other relevant factors. (f) Nothing in this section shall be construed to prohibit a health plan from applying
  payment policies that are consistent with applicable federal or State laws and regulations
  or to relieve a health plan from complying with payment standards established by federal
  or State laws and regulations. (g)(1)(A) Notwithstanding any provision of law to the contrary, on and after March 1, 2014,
  when requiring prior authorization for prescription drugs, medical procedures, and
  medical tests, a health plan shall accept for each prior authorization request either: (i) the national standard transaction information, such as HIPAA 278 standards, for sending
  or receiving authorizations electronically; or (ii) a uniform prior authorization form developed pursuant to subdivisions (2) and (3)
  of this subsection (g). (B) A health plan shall have the capability to accept both the national standard transaction
  information and the uniform prior authorization forms developed pursuant to subdivisions
  (2) and (3) of this subsection (g). (2)(A) Not later than September 1, 2013, the Department of Financial Regulation shall develop
  a clear, uniform, and readily accessible prior authorization form for prior authorization
  requests for medical procedures and medical tests. (B) Not later than September 1, 2013, the Department of Financial Regulation shall develop
  clear, uniform, and readily accessible forms for prior authorization requests for
  prescription drugs after determining the appropriate number of forms. (3) Each uniform prior authorization form developed pursuant to subdivision (2) of this
  subsection shall meet the following criteria, where applicable: (A) The form shall include the core set of common data requirements for nonclinical information
  for prior authorization included in the HIPAA 278 standard transaction, national standards
  for prior authorization and electronic prescriptions, or both. The Department shall
  revise the form as needed to ensure that national standards are adopted and incorporated
  as soon as such standards are available and final. (B) The form shall be made available electronically by the Department and by the health
  plan. (C) The completed form or its data elements may be submitted electronically from the prescribing
  health care provider to the health plan. (D) The Department shall develop the form in consultation with the Department of Vermont
  Health Access and with input from interested parties from at least one public meeting. (E) The Department shall consider input on the proposed form from the national ASC X-12
  workgroup, if available. (F) In developing the uniform prior authorization forms, the Department shall take into
  consideration the following: (i) existing prior authorization forms established by the federal Centers for Medicare
  and Medicaid Services, by the Department of Vermont Health Access, and by insurance
  and Medicaid departments and agencies in other states; and (ii) national standards related to electronic prior authorization. (4)(A)(i) For urgent prior authorization requests, a health plan shall approve, deny, or inform
  the insured or health care provider if any information is missing from a prior authorization
  request from an insured or a prescribing health care provider within 24 hours following
  receipt. (ii) If a health plan informs an insured or a health care provider that more information
  is necessary for the health plan to make a determination on the request, the health
  plan shall have 24 hours to approve or deny the request upon receipt of the necessary
  information. (B) For nonurgent prior authorization requests: (i) A health plan shall approve or deny a completed prior authorization request from an
  insured or a prescribing health care provider within two business days following receipt. (ii) A health plan shall acknowledge receipt of the prior authorization request within
  24 hours following receipt and shall inform the insured or health care provider at
  that time if any information is missing that is necessary for the health plan to make
  a determination on the request. (iii) If a health plan notifies an insured or a health care provider that more information
  is necessary pursuant to subdivision (ii) of this subdivision (4)(B), the health plan
  shall have 24 hours to approve or deny the request upon receipt of the necessary information. (C) If a health plan does not, within the time limits set forth in this section, respond
  to a completed prior authorization request, acknowledge receipt of the request for
  prior authorization, or request missing information, the prior authorization request
  shall be deemed to have been granted. (D) Prior authorization approval for a prescribed or ordered treatment, service, or course
  of medication shall be valid for the duration of the prescribed or ordered treatment,
  service, or course of medication or one year, whichever is longer; provided, however,
  that for a prescribed or ordered treatment, service, or course of medication that
  continues for more than one year, a health plan shall not require renewal of the prior
  authorization approval more frequently than once every five years. (E) For an insured who is stable on a treatment, service, or course of medication, as
  determined by a health care provider, that was approved for coverage under a previous
  health plan, a health plan shall not restrict coverage of that treatment, service,
  or course of medication for at least 90 days upon the insured’s enrollment in the
  new health plan. (h)(1) A health plan shall review the list of medical procedures and medical tests for which
  it requires prior authorization at least annually and shall eliminate the prior authorization
  requirements for those procedures and tests for which such a requirement is no longer
  justified or for which requests are routinely approved with such frequency as to demonstrate
  that the prior authorization requirement does not promote health care quality or reduce
  health care spending to a degree sufficient to justify the administrative costs to
  the plan. (2) A health plan shall attest to the Department of Financial Regulation and the Green
  Mountain Care Board annually on or before September 15 that it has completed the review
  and appropriate elimination of prior authorization requirements as required by subdivision
  (1) of this subsection. (Added 2007, No. 203 (Adj. Sess.), § 29, eff. June 10, 2008; amended 2009, No. 61, § 31; 2011, No. 171 (Adj. Sess.), § 11h; 2013, No. 79, § 5a, eff. June 7, 2013; 2015, No. 54, § 38; 2019, No. 140 (Adj. Sess.), § 8, eff. July 6, 2020; 2023, No. 6, § 232, eff. July 1, 2023; 2023, No. 111 (Adj. Sess.), §§ 3, 4, eff. January 1, 2025; 2025, No. 3, § 2, eff. March 5, 2025.)