Arizona HB 2621: prior authorization; uniform request forms

Bill Text

Chapter 0115 - 551R - H Ver of HB2621 

 House Engrossed

 prior 
 authorization; uniform request forms

 State of 
 Arizona

 House of 
 Representatives

 Fifty-fifth 
 Legislature

 First Regular 
 Session

 2021

 CHAPTER 
 115

 HOUSE BILL 2621

AN ACT

amending 
sections 20-3401 and 20-3403, Arizona Revised Statutes; amending 
title 20, chapter 26, article 1, Arizona Revised Statutes, by adding section 20-3406; 
relating to prior authorization for health care services.

(TEXT OF BILL BEGINS ON NEXT PAGE)

Be it enacted by the Legislature of the State of Arizona:

Section 1. Section 20-3401, Arizona Revised 
Statutes, is amended to read:

START_STATUTE20-3401. Definitions

In this article, unless the context otherwise requires:

1. "Adverse determination":

(a) Means a decision by a health care services plan 
or its utilization review agent that the health care services furnished or 
proposed to be furnished to an enrollee are not medically necessary and plan 
coverage is therefore denied, reduced or terminated.

(b) Does not include a decision to deny, reduce or 
terminate services that are not covered for reasons other than medical 
necessity.

2. "Authorization":

(a) Means a determination by a health care services 
plan or its utilization review agent that a health care service has been 
reviewed and, based on the information provided, satisfies the health care 
services plan's requirements for medical necessity and appropriateness and that 
payment under the plan will be made for that health care service.

(b) Does not include any different or additional 
procedures, services or treatments beyond those specifically reviewed and 
approved by the health care services plan.

3. "Emergency ambulance services" has the 
same meaning prescribed in section 20-2801.

4. "Emergency services" has the same 
meaning prescribed in section 20-2801.

5. "Enrollee" means an individual or a 
dependent of that individual who is currently enrolled with and covered by a 
health care services plan. Enrollee includes an enrollee's legally authorized 
representative.

6. "Health care service":

(a) Means a health care procedure, treatment or 
service for the diagnosis, management or treatment of acute pain, 
chronic pain or opioid use disorder that is covered under 
a health care services plan.

(b) Includes the provision of providing a prescription drug, device or durable medical 
equipment for the treatment or management of acute pain, chronic 
pain or opioid use disorder that is covered under a 
health care services plan.

(c) Does not include treatments that are 
experimental, investigational or off label.

7. "Health care services plan":

(a) Means a plan offered by a disability insurer, 
group disability insurer, blanket disability insurer, health care services 
organization, hospital service corporation or medical service corporation that 
contractually agrees to pay or make reimbursements for health care services 
expenses for one or more individuals residing in this state.

(b) Does not include benefits provided under limited 
benefit coverage as defined in section 20-1137.

8. "Medically necessary" or "medical 
necessity":

(a) Means covered health care services provided by a 
licensed provider acting within the provider's scope of practice in this state 
to prevent or treat disease, disability or other adverse conditions or their 
progression or to prolong life.

(b) Does not include services that are experimental 
or investigational or prescriptions that are prescribed off label.

9. "Medication-assisted treatment" 
has the same meaning prescribed in section 32-3201.01.

10. "pharmacy benefit 
manager" has the same meaning prescribed in section 20-3321.

10. 11. "Prior 
authorization requirement":

(a) Means a practice implemented by a health care 
services plan or its utilization review agent in which coverage of a health 
care service is dependent on an enrollee or a provider obtaining approval from 
the health care services plan before the service is performed, received or 
prescribed, as applicable.

(b) Includes preadmission review, pretreatment 
review, prospective review or utilization review procedures conducted by a 
health care services plan or its utilization review agent before providing a 
health care service.

(c) Does not include case management or step therapy 
protocols.

11. 12. "Provider" 
means a physician, health care institution or other person or entity that is 
licensed or otherwise authorized to furnish health care services in this 
state.� 

12. 13. "Urgent 
health care service" means a health care service with respect to which the 
application of the time periods for making a nonexpedited prior authorization 
decision, in the opinion of a provider with knowledge of the enrollee's medical 
condition, could either:

(a) Seriously jeopardize the life or health of the 
enrollee or the ability of the enrollee to regain maximum function.

(b) Subject the enrollee to severe pain that cannot