Navigating Prior Authorization Regulations: A State-by-State Comparison

In the ever-evolving landscape of healthcare, understanding prior authorization (PA) regulations is crucial for providers, payers, and patients alike. Each state has unique rules governing the timeframe for PA requests, and other critical aspects.

All states mentioned below do require electronic submission for the timelines to apply with the exception of Washington which clarifies

Prior Authorization Regulations Comparison

*For Washington - if the request is not submitted electronically, standard turn around time is 5 days; expedited 2 days

This blog will explore these regulations across several states, highlighting key differences and what they mean for the healthcare community.

Louisiana

Timeframes and Requirements

• Standard Requests: 5 business days
• Urgent Requests: 2 business days
• Gold Card Exemption: No

Key Points

Louisiana mandates that prior authorizations must be valid for a minimum of three months. If a PA request is not processed in a timely manner, claim denial is prohibited solely based on this failure. Additionally, specific clinical review criteria must be provided within 72 hours of the request.

Tennessee

Timeframes and Requirements

• Standard Requests: 7 calendar days
• Urgent Requests: 72 hours plus 1 business day
• Gold Card Exemption: No

Key Points

Tennessee has a unique provision where a request is automatically deemed approved if not processed within the specified timeframes. This state also outlines a specific process for urgent care requests and appeals.

West Virginia

Timeframes and Requirements

• Standard Requests: 5 business days
• Urgent Requests: 2 business days
• Gold Card Exemption: If a health care practitioner has performed an average of thirty (30) procedures per year, and in a six-month time period has received a 90% final prior approval rating, the health insurer may not require prior authorizations for that procedure for at least the next six-month period, or longer if the insurer allows

Key Points

West Virginia requires electronic submission via an electronic portal and mandates quarterly reporting to the Offices of the Insurance Commissioner (OIC). Non-compliance can result in civil penalties.

Montana

Timeframes and Requirements

• Gold Card Exemption: A health insurance issuer that uses a prior authorization process for benefits may not require a provider to obtain prior authorization for a particular benefit if, in the most recent 6-month evaluation period, as described in subsection, the health insurance issuer has approved or would have approved not less than 90% of the prior authorization requests submitted by the provider for the particular benefit.

Key Points

Montana allows providers the right to an independent external review for adverse determinations. Providers meeting specific criteria are exempt from prior authorization requirements.

Oklahoma

Timeframes and Requirements

• Standard Requests: 7 days
• Urgent Requests: 72 hours
• Gold Card Exemption: No

Key Points

Oklahoma mandates the implementation of a Prior Authorization Application Programming Interface (API) by 2027. The state also specifies requirements for emergency healthcare services and continuity of care.

Illinois

Timeframes and Requirements

• Standard Requests: 5 calendar days
• Urgent Requests: 48 hours
• Gold Card Exemption: Available

Key Points

In Illinois, non-urgent requests must be processed within five calendar days, and urgent requests within 48 hours. Providers meeting approval criteria for six months can obtain a Gold Card exemption. For chronic conditions, PA validity can extend up to 12 months.

Washington

Timeframes and Requirements

• Standard Requests*:
  • Electronic Submission - 3 calendar days
  • Non Electronic Submission - 5 calendar days
• Urgent Requests:
  • Electronic Submission - 1 calendar days
  • Non Electronic Submission - 2 calendar days
• Gold Card Exemption: No

*Holidays not counted in timeline

Key Points

Washington is focusing on interoperability and reducing administrative burdens on providers. The state requires an API for prior authorizations by 2025 for healthcare services and by 2027 for prescription drugs.

Looking Ahead

Navigating the complexities of prior authorization regulations requires understanding the nuances of each state's requirements. From timeframes for standard and urgent requests to electronic submission mandates and exemptions, staying informed is essential for compliance and efficient healthcare delivery.

As states continue to refine their regulations, keeping abreast of these changes will help healthcare providers and payers ensure they meet legal requirements and provide timely care to patients.

If you find new or additional information regarding prior authorization legislation don’t hesitate to reach out to us at hello@genhealth.ai so we can update this article.