Updated 09/22/23
If a health benefit plan's appeal process involves two steps, those steps should be counted as a single “appeal” for purposes of the FIS 2379.
Section 2212e(17)(m) defines “prior authorization” as “a determination by an insurer or utilization review organization that a requested health care benefit has been reviewed and, based on the information provided, satisfies the insurer or utilization review organization requirements for medical necessity and appropriateness.” A request for such a determination relates to whether the requested benefit may be covered under the plan by meeting requirements relating to “medical necessity and appropriateness.” The statute’s definition does not make an express distinction based on a patient’s “liability” stemming from a provider’s contractual relationship the insurer. Additionally, federal law generally requires coverage of emergency services “without the need for any prior authorization determination.” See 42 USC 300gg-111; 45 CFR 149.110.
Section 2212e(17)(m) defines “prior authorization” as “a determination by an insurer or utilization review organization that a requested health care benefit has been reviewed and, based on the information provided, satisfies the insurer or utilization review organization requirements for medical necessity and appropriateness.” A request for such a determination relates to whether the requested benefit may be covered under the plan by meeting requirements relating to “medical necessity and appropriateness.” The statute’s definition does not make an express distinction based on a patient’s “liability” stemming from a provider’s contractual relationship the insurer.
The definition of “prior authorization” under MCL 500.2212e(17)(m) applies regardless of when the provider makes the request. The statute’s definition does not make an express distinction based on whether a patient is already receiving services at the time of the request.
Section 2212e(17)(n) defines “standardized electronic prior authorization transaction process” as “a standardized transmission process, identified by the director and aligned with standards that are nationally accepted, to enable prior authorization requests to be accessible, submitted by health care providers, and accepted by insurers or their designee utilization review organizations electronically through secure electronic transmissions with the goal of maximizing administrative simplification, efficiency, and timeliness. The process must allow health care providers to supply clinical information under the standardized electronic prior authorization process. Standard electronic prior authorization transaction process does not include a facsimile.” The Department has issued a bulletin setting forth the nationally accepted standards that will be considered to satisfy this requirement when used by insurers. The bulletin will be updated as necessary to identify new standards or to eliminate outdated standards.
An insurer should submit a detailed description of how it will comply with MCL 500.2212e(1) to the Department in SERFF under filing type "Prior Authorization Std Electronic Request Process." This description should be submitted by May 1, 2023 for all non-ACA filings. ACA issuers will submit their description by May 10, 2023 for small group ACA filings, and by May 31, 2023 for individual ACA filings. Each submission will be subject to review by Department staff. If an insurer implements a new prior authorization requirement or restriction, or amends an existing requirement or restriction, or amends its existing process, it must submit a new description to the Department no later than 60 days before implementation.
Yes. Insurers subject to Section 2212e must ensure compliance with the reporting requirements under the statute. This includes prior authorization requests processed by a third party administrator or pharmacy benefit manager. See MCL 500.2212c(8)(b)(iv).
No (assuming that “FDR” is intended to refer specifically to that term defined under federal law). The Centers for Medicare and Medicaid Services (CMS) defines FDRs as entities that provide certain services or functions to Medicare Advantage Organizations and Medicare Part D plan sponsors or in relation to Medicare Advantage or Part D benefits or enrollees. See 42 CFR 423.501. The Medicare Advantage and Part D programs are regulated under the authority of CMS, not the Department of Insurance and Financial Services (DIFS). Further, MCL 500.2212e applies to health benefit plans, which term is defined in subsection (17)(d) and does not include Medicare Advantage or Medicare. Accordingly, an insurer is not required to report to DIFS information on prior authorizations conducted pursuant these federal benefit programs for the purposes of Section 2212e(13).
No, unless the required information regarding the insurer’s standardized electronic prior authorization transaction process differs in any way among its plans and/or products. Pursuant to Bulletin 2023-05-INS, insurers should submit at least one filing relating to its standardized electronic prior authorization transaction process established in compliance with MCL 500.2212e. That filing must list the names of all the products and plans to which the process applies. Further, a separate filing is required for any other plan or product if the information regarding the applicable standardized electronic prior authorization transaction process differs in any way from a filing already submitted.
No. Section 2212e does not contain an exception for health professionals to, at their discretion, opt out of using the insurer’s standardized electronic prior authorization transaction process, beginning June 1, 2023. However, the statute does not mandate the use of that process if “the health professional is not able to use the standard electronic prior authorization transaction process because of a temporary technological or electrical failure.”
Yes, as long as the prior authorization request is directed toward an insurer subject to Section 2212e as an insurer that delivers, issues for delivery, renews, or administers a health benefit plan in Michigan. Section 2212e(f) defines “health professionals” as individuals licensed, registered, or otherwise authorized to engage in a health profession under Article 15 of Michigan’s Public Health Code, MCL 333.16101 to 333.18838, or under the laws of another State.
Section 2212e does not expressly specify the manner in which an appeal must be filed. However, upon denying a prior authorization request, the insurer (or its utilization review organization) must provide instructions on how to file the appeal to both the health professional and insured/enrollee. See MCL 500.2212e(7)(c).
Individual and small group issuers will submit with their ACA-compliant filings. Filings deadlines are May 10, 2023 for small group and May 31, 2023 for individual. Issuers who need flexibility should contact DIFS directly.
Health plans should consult with internal legal counsel regarding the posting of any proprietary material.
