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Senate of Pennsylvania
Session of 2019 - 2020 Regular Session


Posted: June 20, 2019 01:43 PM
From: Senator Kristin Phillips-Hill
To: All Senate members
Subject: Prior Authorization of Medical Services in Pennsylvania
In the near future I will introduce legislation to streamline and standardize the process for prior authorization of medical services in Pennsylvania. Prior authorization refers to any process by which physicians and other health care providers must obtain advance approval from a health plan before a specific procedure or service is delivered to the patient to qualify for payment coverage.

As implemented currently in the Commonwealth, the prior authorization procedure is too often an inefficient process that increases costs for providers, their patients and all policy holders. Significant delays in patients receiving needed treatments continue to be reported because of unnecessary challenges in the prior authorization process. The lack of standardization of paperwork; lack of transparency, accessibility and consistent application of prior authorization requirements, restrictions and amendments; and lack of electronic submission capability all contribute to the impaired delivery of quality health care to our constituents.

My bill will improve transparency, accessibility and consistent application of prior authorization by including a standard definition. It will also significantly streamline the process by requiring insurers to make available an electronic communications network that permits prior authorization requests to be submitted electronically, and authorizations and adverse determinations to likewise be returned electronically.

Transparency and consistent application of prior authorization criteria and clinical expectations will be enhanced by requiring the disclosure of prior authorization requirements, restrictions and/or amendments to subscribers and physicians. Improved patient care will result from requiring consistent response times and processes with respect to prior authorizations, adverse determinations, and appeal procedures, including external review. And practice efficiency will be improved by establishing limitations on routine medical record requests by insurers.

A key element of the bill will be the development of a standard prior authorization form that can be electronically submitted by all health care providers and accepted by all health insurers.

Please join me in co-sponsoring this important health care reform legislation

Introduced as SB920