44-5440.

Prior authorization; provision of care permitted; conditions; health care service; payments; rate.

(1) A utilization review agent shall not revoke, limit, condition, or restrict an approved prior authorization if care is provided within sixty days from the date the health care provider received the prior authorization approval unless the enrollee was no longer eligible for care on the day care was provided.

(2) A health carrier shall pay a contracted health care provider at the contracted payment rate for a health care service provided by the health care provider per an approved prior authorization request, unless:

(a) The health care provider knowingly and materially misrepresented the health care service or patient's medical history in the prior authorization request with the intent to deceive and obtain an unlawful payment under the health benefit plan;

(b) The health care service was no longer a covered benefit on the day it was provided;

(c) The health care provider was no longer contracted with the patient's health benefit plan on the date the care was provided;

(d) The health care provider failed to meet the utilization review agent's timely filing requirements;

(e) The patient was no longer eligible for health care coverage on the day the care was provided; or

(f) The health care provider failed to obtain prior authorization approval before rendering health care services for which prior authorization was required.