(a) Establishment of provider portal.--Within 18 months following the effective date of this section, an insurer or MA or CHIP managed care plan shall establish a provider portal that includes, at minimum, the following features:
(1) Electronic submission of prior authorization requests.
(2) Access to the insurer's or MA or CHIP managed care plan's applicable medical policies.
(3) Information necessary to request a peer-to-peer review.
(4) Contact information for the insurer's or MA or CHIP managed care plan's relevant clinical or administrative staff.
(5) For any health care service that requires prior authorization that is not subject to electronic submission via the provider portal, copies of applicable submission forms.
(6) Instructions for the submission of prior authorization requests if the insurer's or MA or CHIP managed care plan's provider portal is unavailable for any reason.
(b) Training and support for portal use.--Within six months following the establishment of a provider portal under subsection (a), an insurer or MA or CHIP managed care plan shall make available to health care providers and their affiliated or employed staff access to training on the use of the insurer's or MA or CHIP managed care plan's provider portal.
(c) Required use of provider portal.-- (1) Within 18 months following the establishment of a provider portal under subsection (a), a health care provider seeking prior authorization shall submit the request via an insurer's or MA or CHIP managed care plan's provider portal unless an exception applies.
(2) An insurer or MA or CHIP managed care plan may require a health care provider to submit a prior authorization request through the provider portal unless any of the following exceptions applies:
(i) The portal is not available and operational at the time of attempted submission.
(ii) The health care provider does not have access to the insurer's or MA or CHIP managed care plan's operational provider portal.
(iii) The health care provider satisfies an allowance by the insurer or MA or CHIP managed care plan for submission other than through the provider portal.
Credits
1921, May 17, P.L. 682, No. 284, § 2153, added 2022, Nov. 3, P.L. 2068, No. 146, § 5, effective Jan. 1, 2023.
40 P.S. § 991.2153, PA ST 40 P.S. § 991.2153
Current through Act 10 of the 2024 Regular Session. Some statute sections may be more current, see credits for details.
