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23-99-1109. Rescission of prior authorizations — Denial of payment for prior authorized services — Limitations.
Arkansas Code — all titles (historical 2020) · legal_authorities
23-99-1109. Rescission of prior authorizations — Denial of payment for prior authorized services — Limitations.
(a) A decision on a request for prior authorization by a utilization review entity shall include a determination as to whether or not the individual is covered by a health benefit plan and eligible to receive the requested service under the health benefit plan.
(b)(1) A utilization review entity shall not rescind, limit, condition, or restrict an authorization based upon medical necessity unless the utilization review entity notifies the healthcare provider at least three (3) business days before the scheduled date of the admission, service, procedure, or extension of stay.
(2) Notwithstanding subdivision (b)(1) of this section, a utilization review entity may rescind, limit, condition, or restrict an authorization if:
(A) The subscriber was not covered by the health benefit plan and was not eligible to receive the requested service under the health benefit plan on the date of the admission, service, procedure, or extension of stay; and
(B) The utilization review entity has provided to the healthcare provider a means to confirm whether or not the subscriber is covered by the health benefit plan and eligible to receive the requested service up to the date of admission, service, procedure, or extension of stay.
(c) A healthcare insurer shall pay a claim for a healthcare service for which prior authorization was received regardless of the terminology used by the utilization review entity or health benefit plan when reviewing the claim, unless:
(1) The authorized healthcare service was never performed;
(2) The submission of the claim for the healthcare service with respect to the subscriber was not timely under the terms of the applicable provider
Source: Arkansas Code — historical release 78 (November 6, 2020) · 23-99-1109
Stored review status: Historical 2020-11-06 source release; later amendments not reconciled; machine-extracted, not independently legally reviewed; source heading status: text_in_historical_source. A text match is a research starting point; applicability is not established.
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Stable record: arkansas_code:legal_authorities:23-99-1109
Source file: gov.ar.code.title.23.odt
Pages: Not recorded – Not recorded
Passage SHA-256: 35b23739dc2e5f1fa756fade4cc2f44a8c5c2ba3784d49927b81d6057a1cd6ff
Source location: content.xml paragraph 59684
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23-99-1109. Rescission of prior authorizations — Denial of payment for prior authorized services — Limitations.
(a) A decision on a request for prior authorization by a utilization review entity shall include a determination as to whether or not the individual is covered by a health benefit plan and eligible to receive the requested service under the health benefit plan.
(b)(1) A utilization review entity shall not rescind, limit, condition, or restrict an authorization based upon medical necessity unless the utilization review entity notifies the healthcare provider at least three (3) business days before the scheduled date of the admission, service, procedure, or extension of stay.
(2) Notwithstanding subdivision (b)(1) of this section, a utilization review entity may rescind, limit, condition, or restrict an authorization if:
(A) The subscriber was not covered by the health benefit plan and was not eligible to receive the requested service under the health benefit plan on the date of the admission, service, procedure, or extension of stay; and
(B) The utilization review entity has provided to the healthcare provider a means to confirm whether or not the subscriber is covered by the health benefit plan and eligible to receive the requested service up to the date of admission, service, procedure, or extension of stay.
(c) A healthcare insurer shall pay a claim for a healthcare service for which prior authorization was received regardless of the terminology used by the utilization review entity or health benefit plan when reviewing the claim, unless:
(1) The authorized healthcare service was never performed;
(2) The submission of the claim for the healthcare service with respect to the subscriber was not timely under the terms of the applicable provider contract or policy;
(3) The subscriber had not exhausted contract or policy benefit limitations based on information available to the utilization review entity or healthcare insurer at the time of the authorization but subsequently exhausted contract or policy benefit limitations after the authorization was issued, in which case the utilization review entity or healthcare insurer shall include language in the notice of authorization to the subscriber and healthcare provider that the visits or services authorized might exceed the limits of the contract or policy and would accordingly not be covered under the contract or policy;
(4) There is specific information available for review by the appropriate state or federal agency that the subscriber or healthcare provider has engaged in material misrepresentation, fraud, or abuse regarding the claim for the authorized service; or
(5) The authorization was granted more than ninety (90) days before the authorized healthcare service is provided.
(d)(1)(A) A utilization review entity doing business in this state shall strive to implement no later than July 1, 2018, a mechanism by which healthcare providers may request prior authorizations through an automated electronic system as an alternative to telephone-based prior authorization systems.
(B) The State Insurance Department may promulgate a rule mandating the implementation of a mechanism described in this subsection and defining the services to which this subsection applies.
(2) A healthcare provider shall retain the ability to use either the automated electronic system or a telephone-based system.
(3) The automated electronic system shall be capable of handling benefit inquiries under § 23-99-1113.
(e) A service authorized and guaranteed for payment under this section for which the prior authorization is not rescinded or reversed under subsection (b) of this section is not subject to audit recoupment under § 23-63-1801 et seq., except as provided for in subsection (b) of this section.
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Arkansas Code — all titles (historical 2020) · legal_authorities
23-63-1801. Definitions.
As used in this subchapter:
(1) “Covered person” means a person on whose behalf a health care insurer offering health insurance coverage is obligated to pay benefits or provide services;
(2) “Healthcare insurer” means an entity subject to the insurance laws of this state or the jurisdiction of the Insurance Commissioner that contracts or offers to contract to provide health insurance coverage, including, but not limited to, an insurance company, a health maintenance organization, or a hospital medical service corporation;
(3) “Healthcare provider” means any person or entity providing:
(A) Medical, pharmaceutical, optometric, or dental care;
(B) Hospitalization; or
(C) Any other services and goods used for the purpose or incidental to the purpose of preventing, alleviating, curing, or healing human illness or injury;
(4)(A) “Health insurance coverage” means benefits consisting of medical, pharmaceutical, optometric, or dental care, hospitalization, or other goods or services for the purpose of preventing, alleviating, curing, or healing human illness provided, directly or indirectly, through insurance, reimbursement, or otherwise, including items and services paid for under any policy, certificate, or agreement offered by a health care insurer.
(B) “Health insurance coverage” does not include policies or certificates covering only accident, credit, disability income, long-term care, hospital indemnity, Medicare supplemental policy as defined in 42 U.S.C. § 1395ss(g)(1), a specified disease, other limited benefit health insurance, automobile medical payment insurance, or claims under the Workers' Compensation Law, § 11-9-101 et seq., Public Employee Workers' Compensation Act, § 21-5-601 et seq., or the Comprehensive Health Insuran
Source: Arkansas Code — historical release 78 (November 6, 2020) · 23-63-1801
Stored review status: Historical 2020-11-06 source release; later amendments not reconciled; machine-extracted, not independently legally reviewed; source heading status: text_in_historical_source. The source passage cites 23-63-1801. This identifies an authority to review, not proof of applicability.
Arkansas Code — all titles (historical 2020) · legal_authorities
23-99-1113. Benefit inquiries authorized.
(a)(1) An in-network or out-of-network healthcare provider may submit a benefit inquiry to a healthcare insurer or utilization review entity for a healthcare service not yet provided to determine whether or not the healthcare service meets medical necessity and all other requirements for payment under a health benefit plan if the healthcare service were to be provided to a specific subscriber.
(2)(A) The State Insurance Department shall issue a rule on or before January 1, 2018, that defines which benefits are subject to the requirements of this section.
(B) Until a rule is promulgated under subdivision (a)(2)(A) of this section, all benefit inquiries shall be processed according to this section.
(b) If a healthcare insurer or utilization review entity lacks sufficient information to respond to a benefit inquiry, the healthcare insurer or utilization review entity shall notify the healthcare provider within two (2) business days of the additional information that is required to respond to the benefit inquiry.
(c)(1) A healthcare insurer, either directly or through a utilization review entity, shall respond to a benefit inquiry authorized in subsection (a) of this section within ten (10) business days of receipt of information required to make a decision on the benefit inquiry.
(2) Responses to a benefit inquiry shall be provided in the same form and manner as responses to requests for prior authorization.
(d) Every healthcare insurer shall provide a convenient and accessible procedure for healthcare providers to submit benefit inquiries under this section.
(e) Sections 23-99-1109 — 23-99-1111 and 23-99-1114 — 23-99-1116 apply to the benefit inquiry process of any healthcare insurer or utilization review entity.
Source: Arkansas Code — historical release 78 (November 6, 2020) · 23-99-1113
Stored review status: Historical 2020-11-06 source release; later amendments not reconciled; machine-extracted, not independently legally reviewed; source heading status: text_in_historical_source. The source passage cites 23-99-1113. This identifies an authority to review, not proof of applicability.