44-5438.

Prior authorization; decision; notice; when required.

(1) Prior to January 1, 2028, if a utilization review agent requires prior authorization of a health care service, the utilization review agent shall make a decision on the prior authorization request and provide notice of its decision to the enrollee and the enrollee's health care provider in accordance with the following timeframes:

(a) For a prior authorization request for urgent health care services, within seventy-two hours after obtaining all necessary information to make a decision; or

(b) For a prior authorization request for nonurgent health care services, within seven days after obtaining all necessary information to make a decision.

(2) Beginning January 1, 2028, if a utilization review agent requires prior authorization of a health care service, the utilization review agent shall make a decision on the prior authorization request and provide notice of its decision to the enrollee and the enrollee's health care provider in accordance with the following timeframes:

(a) For a prior authorization request for urgent health care services, within forty-eight hours after obtaining all necessary information to make a decision; or

(b) For a prior authorization request for nonurgent health care services, within seven days after obtaining all necessary information to make a decision.

(3) Nothing in this section prohibits a health care provider and health carrier from contracting for shorter timeframes for using the prior authorization application programming interface or other electronic prior authorization methodology described in subsection (2) of section 44-5437 or as part of a risk-sharing agreement.

(4) Health care services are deemed authorized if a utilization review agent fails to comply with the deadlines for making a decision as set forth in this section.

(5) In the notice to the health care provider that a prior authorization has been approved, the utilization review agent shall include the duration of the prior authorization or the date by which the prior authorization will expire.