Creates provisions relating to prior authorization of health care services
Summary
HB 1675 would add new sections to Missouri’s insurance code governing prior authorization for health care services. The bill limits when a health carrier or utilization review entity may require prior authorization from a provider. In general, a carrier could only impose prior authorization for a specific service if, during the most recent six-month evaluation period, it approved or would have approved less than 90% of that provider’s prior authorization requests for that service. A similar 90% threshold would apply to all services combined before a carrier could require prior authorization at all for that provider.
The bill also requires carriers and utilization review entities to notify providers within 25 days after each evaluation period whether the threshold has been met, and to include supporting statistics and documentation. It requires an appeal process and an online portal showing prior authorization status, notices, dates received, and related information. In addition, the bill prohibits denial or reduction of payment for a service that was prior authorized unless the provider knowingly and materially misrepresented the service with intent to deceive, or failed to substantially perform the service.
Impact
The bill would create new statutory protections for health care providers by restricting the use of prior authorization and by limiting post-authorization payment denials. It would amend Chapter 376, RSMo, by adding sections 376.2100 through 376.2108, affecting health carriers, utilization review entities, and providers participating in health benefit plans. The bill excludes MO HealthNet generally, but includes Medicaid managed care organizations within the definition of health carrier for these provisions, and it does not apply to providers who have not participated in a plan for at least one full evaluation period.
Sentiment
The available record shows no committee transcript, recorded votes, or formal debate, so there is no documented public sentiment from the legislative process in the materials provided. Based on the bill’s structure, it appears designed to address provider frustration with prior authorization burdens and to increase transparency and predictability in insurer decision-making. The absence of recorded opposition or amendment activity in the provided context makes it difficult to assess the balance of support and concern.
Contention
The main policy tension in HB 1675 is between reducing administrative burden on providers and preserving insurers’ ability to manage utilization and control costs. Supporters would likely favor the 90% approval threshold, appeal rights, and payment protections as ways to curb overly restrictive prior authorization practices. Potential opponents or skeptics may object that the bill could limit utilization review tools, increase plan costs, or reduce flexibility in managing medical necessity. The bill also draws a line around MO HealthNet and Medicaid managed care organizations, which could be a point of interest for stakeholders concerned about public program coverage.