On this page, you’ll find in-depth information on the transparency provisions of the new OIC rule governing the programs used by insurers and third-party administrators for the prior authorization of medical services.
The term “physician” is used on this page primarily for convenience. Other categories of health professionals may also be affected by the new rule. In some case, it may be appropriate to delegate certain actions to non-clinical staff.
TPA = Third-party administrator
Patient-specific information for determination
Starting Nov. 1, 2019, insurance carriers and TPAs must have available for physicians a “current and accurate online prior authorization process” that provides the patient-specific information needed to determine if a service is a benefit under the enrollee’s plan and the information necessary to submit a complete prior authorization request. The online process must provide information required for a physician to determine, for a specific patient’s plan, and for a specific service:
- If the service is a benefit.
- If prior authorization request is necessary.
- What, if any, preservice requirements apply.
- If a prior authorization is required, the following information:
- The clinical criteria used to evaluate the request.
- Any required documentation.
Insurance carriers and TPAs need not update the “current and accurate” online system in real-time; overnight updating is sufficient.
Integrated delivery systems are not required to comply with this provision for their physician employees participating through the integrated delivery system.
Clinical review criteria
Insurance carriers and TPAs must document their prior authorization program and use evidence-based clinical review criteria when making determinations.
All insurance carriers’ prior authorization clinical review criteria must be posted online. According to the OIC, access to prior authorization criteria can be restricted to only participating physicians and facilities via a password-protected website and limited to the criteria of the service in question, but there are no exceptions for proprietary criteria.
Clinical review criteria used to evaluate requests for services must be provided to physicians and facilities before submitting a request, per the patient-specific information for determination discussed above.
If a request is denied, the response from the insurance carrier or TPA must give the specific reason for the denial in “clear and simple” language. If the request is denied based on clinical review criteria, the criteria used to make the determination must be provided. (See: Communication requirements)
A prior authorization program must have staff who are properly qualified, trained, supervised, and supported by explicit written, current clinical review criteria and review procedures. (See: Prior authorization program staff requirements)
Documentation retention system
Insurance carriers and TPAs must maintain a system of documenting information and supporting evidence submitted by physicians. This information must be kept on file until the claim has been paid or the appeals process has been finalized. (See: Medical record requests and documentation)
Changes to prior authorization program requirements
The OIC recognizes the challenges created for physicians when insurance carriers change their prior authorization program’s requirements with little or no notice.
Under existing law, changes that affect a physician’s or facility’s compensation or health care service delivery must be given 60-days prior notice. This includes changes to prior authorization programs.
Insurance carriers and TPAs must give physicians 60-days prior notice before making any changes to its prior authorization program, including the addition of new prior authorization requirements to services or changes to the clinical criteria used to consider prior authorization requests.