Health insurance carriers engage in a process known as “utilization review” or “prior authorization” which is a system where the carrier reviews a practitioner’s request that a patient receive a certain health care service to determine if the service is medically necessary.

This legislation would reform prior authorization by:

1. Require evidence-based, peer reviewed criteria as the standard of care developed by an organization that works directly with health care providers or a professional medical specialty society.
2. Mandate that a physician which made or participated in the adverse decision notify the insured’s physician or health care practitioner prior to making the adverse decision and be available to discuss the basis for the denial and the medical necessity of the health care service rather than deny care and then allow for a peer-to-peer meeting after the fact.
3. Created a timeline for response by carriers for requests for services or extension of services within 1 working day AND approve requests automatically when a private review agents fails to respond to a request in the mandated amount of time.
4. Study the feasibility of a “gold card” standard in Maryland, which would exempt health care practitioners who meet certain standards from prior authorization standards.

Questions?