More Transparency/Efficiency in Utiliz. Rev
Senate Bill 315 would revise North Carolina’s insurance utilization review laws to increase transparency, speed, and consistency in prior authorization and related medical-necessity decisions. The bill shortens decision timelines for prospective and concurrent reviews, requiring determinations for non-urgent services within three business days after all necessary information is received and urgent services within 24 hours, with an exception when electronic health record access is not shared. It also requires clearer notice to patients and providers when services are certified or denied, and it makes insurers remain liable for concurrent services until a noncertification is communicated.
The bill adds stronger standards for appeals by requiring review by a qualified, independent physician or, for certain mental health services, a similarly qualified licensed mental health professional. It also expands disclosure obligations by requiring insurers to describe utilization review procedures in member materials, on websites, and on membership cards, and it bars denial of claims based on prior authorization requirements that were not properly posted online when the service was rendered. In addition, it extends the validity of some prior authorizations, including a 90-day carryover when a person changes to a new plan from the same insurer and at least six months for chronic-condition services that are not inpatient care.
The bill would amend G.S. 58-50-61 and related insurance provisions governing utilization review, affecting commercial health insurers, utilization review organizations, providers, and covered persons in North Carolina. It also directs the State Treasurer and State Health Plan administrators to review State Health Plan practices and third-party contracts for compliance with the new standards. The bill further requires insurers to implement a prior authorization API meeting federal requirements by January 1, 2028, and prohibits the use of artificial intelligence as the sole basis for denying, delaying, or modifying health care services, reserving final utilization review decisions to qualified individuals.
No committee transcripts or recorded votes were provided, so there is no direct evidence of debate or opposition in the available materials. Based on the bill text, the measure appears designed to address common complaints about prior authorization delays and opaque utilization review practices, suggesting a consumer- and provider-friendly policy direction. The overall framing is reform-oriented and administrative rather than punitive, with an emphasis on transparency, timeliness, and accountability.
The most likely points of contention are the bill’s restrictions on insurer discretion, especially the tighter turnaround times, the requirement that appeals be reviewed by independent licensed clinicians, and the prohibition on using artificial intelligence as the sole basis for adverse utilization review decisions. Insurers and utilization review vendors may object to the operational burden, compliance costs, and limits on automated review tools, while patient advocates and providers are likely to support the added protections. Another possible area of dispute is the requirement that prior authorization remain valid for extended periods in certain circumstances, which could be viewed as reducing administrative flexibility for insurers.