ALL of the following

• Adverse determinations of clean pre-authorization must be made by a physician who: - Is not compensated based on the outcome of the review; and - Is licensed in any U.S. jurisdiction; and - Either has appropriate training, knowledge, or experience in the same or similar specialty that typically manages or consults on the health-care service in review, or consults with a qualified third-party provider licensed in the relevant specialty (who also is not compensated based on the outcome).

  Citing physician review requirements for clean pre-authorizations.

• Appeals by physicians must be reviewed by a physician who meets the same physician review criteria, possesses an active, unrestricted license in good standing in any U.S. jurisdiction, was not directly involved in the original determination, and reviews and considers all clinical aspects and relevant documentation.

  Physician appeal review additional requirements.

When request submitted by non-physician provider

• A health-care provider licensed in the same or similar profession as the requesting provider.
• A licensed health-care provider in consultation with a qualified third-party provider licensed in the same or similar medical specialty as the requesting provider.

ALL of the following

• Utilization review entities must notify the covered person and provider of the appeal decision within 15 days of receiving an appeal.
• If required documentation or clinical information is missing, the entity must notify the covered person and provider in writing within the 15-day window and specify what is required.
• Once the requested information is received, the entity has an additional 15 days to issue a final determination and notify all parties.
• Written determination on appeal must include a summary of findings supporting the decision, the qualifications of the reviewer(s) (licenses, certifications, or specialties), and the clinical rationale linking diagnosis/condition to the review criteria and specific basis for the determination.
• Covered persons and providers must be given at least 30 days from the adverse determination date to submit an appeal.

ALL of the following

• Utilization reviews must be conducted seven days a week.
• A medical director or clinical decision-maker must be available Monday–Friday 7:00 AM–7:00 PM and Saturday–Sunday during reasonable business hours.
• Appeals must be accepted in writing, electronically, or by telephone.

ALL of the following

• Pharmaceutical benefit requests: response within 2 business days of receiving a clean request.
• Standard requests (non-electronic): response within 5 business days.
• Standard requests (electronic): response within 3 business days.
• Urgent health-care services (non-electronic): response within 48 hours.
• Urgent health-care services (electronic): response within 24 hours.
• Patient transfers follow urgent timeframes: non-electronic 48 hours; electronic 24 hours.

ALL of the following

• Authorizations must remain valid for at least 90 days from the provider's receipt of the determination, or longer if clinically appropriate, subject to continued coverage, eligibility, and properly-noticed policy changes.

ALL of the following

• Insurers, plans, health-service corporations, and utilization review entities must accept and respond to electronic pre-authorization requests via the same platform used for submission (e.g., website, mobile app, digital portal).
• By no later than January 1, 2027, each entity must establish a provider portal that includes: electronic submission of pre-authorization requests; access to applicable medical policies; information necessary to request a peer-to-peer review; contact information for relevant clinical or administrative staff; copies of applicable forms for services not subject to electronic submission; and instructions for submission if the portal is unavailable.
• Within 12 months following establishment of a provider portal, a health-care provider may be required to submit requests via the portal unless an exemption applies (portal unavailable/ not operational at time of submission; provider lacks access to the operational portal; provider has an approved alternate submission method).

ALL of the following

• Only one pre-authorization is required per episode of care; new or unrelated treatments, tests, or procedures may require separate authorization. In bundled payment arrangements, in-network covered services are deemed approved as provided by the payer.
• Medically necessary interfacility transport does not require pre-authorization.
• Insurers must provide at least six months' advance notice to covered persons before implementing utilization review term changes, except for updated clinical guidelines, product recalls, market withdrawals, or FDA safety alerts.