North Carolina SB 315: More Transparency/Efficiency in Utiliz. Rev.

Bill Text

GENERAL ASSEMBLY OF NORTH CAROLINA
SESSION 2025
S 1
SENATE BILL 315

Short Title: More Transparency/Efficiency in Utiliz. Rev. (Public)
Sponsors: Senators Burgin, Galey, and Sawrey (Primary Sponsors).
Referred to: Health Care
March 18, 2025
*S315-v-1*
A BILL TO BE ENTITLED 1
AN ACT TO INCREASE TRANSPARENCY AND EFFICIENCY IN UTILIZATION 2
REVIEWS. 3
The General Assembly of North Carolina enacts: 4
SECTION 1.(a) G.S. 58-50-61 reads as rewritten: 5
"§ 58-50-61. Utilization review. 6
(a) Definitions. – As used The following definitions apply in this section, in 7
G.S. 58-50-62, and in Part 4 of this Article, the term:Article: 8
... 9
(16a) Urgent health care service. – A health care service with respect to which the 10
application of the time periods for making an urgent care determination that, 11
in the opinion of a physician with knowledge of the covered person's medical 12
condition, meets either of the following criteria: 13
a. Could seriously jeopardize the life or health of the covered person or 14
the ability of the covered person to regain maximum function. 15
b. Would subject the covered person to severe pain that cannot be 16
adequately managed without the care or treatment that is the subject 17
of the utilization review. 18
... 19
(f) Time Lines for Prospective and Concurrent Utilization Reviews Based Upon Type of 20
Health Care Service. – As used in this subsection, the term "necessary information" includes the 21
results of any patient examination, clinical evaluation, or second opinion that may be required. 22
Prospective and concurrent determinations shall be communicated to The time line for 23
completion of a prospective or concurrent utilization review is as follows: 24
(1) Non-urgent health care services. – If an insurer requires a utilization review of 25
a healthcare service, then the insurer or its URO shall both render a utilization 26
review determination or noncertification and notify the covered person and the 27
covered person's provider within three business days after the insurer obtains 28
all necessary information about the admission, procedure, or health care 29
service. to make the utilization review determination or noncertification. 30
(2) Urgent health care services. – An insurer or its URO shall both render a 31
utilization review determination or noncertification concerning urgent health 32
care services and notify the covered person and the covered person's provider 33
of that utilization review determination or noncertification not later than 24 34
hours after receiving all necessary information needed to complete the review 35
of the requested health care services. If the covered person's provider or the 36

General Assembly Of North Carolina Session 2025
Page 2 Senate Bill 315-First Edition
insurer, or the entity conducting the review on behalf of the insurer, do not 1
both have access to the electronic health records of the covered person, then 2
this subdivision shall not apply and the utilization review will be subject to 3
the time line under subdivision (1) of this subsection. 4
(f1) Utilization Review Determination Notifications. – If an insurer or its URO certifies a 5
health care service, the insurer shall notify notification shall be sent to the covered person's 6
provider. For If an insurer or its URO issues a noncertification, the insurer shall notify the covered 7
person's provider and send then written or electronic confirmation of the noncertification to the 8
covered person's provider and covered person. In person that is in compliance with subsection 9
(h) of this section. 10
(f2) Concurrent Review Liability. – For concurrent reviews, the insurer shall remain liable 11
for health care healthcare services until the covered person has been notified of the 12
noncertification. 13
... 14
(j1) Requirements Applicable to Appeals Reviews. – All of the following requirements 15
apply to an appeals review: 16
(1) Except as otherwise provided, appeals shall be reviewed by a medical doctor 17
who meets all of the following criteria: 18
a. Possesses a current and valid non-restricted license to practice 19
medicine in any United States jurisdiction. 20
b. Has practiced for a period of at least three consecutive years in the 21
same or similar specialty as a medical doctor who typically manages 22
the medical condition or disease for which utilization review is 23
required or whose training and experience meets all of the following 24
criteria: 25
1. Includes treatment of the same condition as the condition of 26
the covered person. 27
2. Includes treatment of complications that may result from the 28
service or procedure that is the subject of the appeal. 29
3. Is sufficient for the medical doctor to determine if the service 30
or procedure is medically necessary or clinically appropriate. 31
c. Had no direct involvement in making any prior adverse determination 32
or noncertification. 33
d. Has no financial interest, or other conflict of interest, in the outcome