Prior authorization; denial of claims

A. A health insurance issuer shall not deny any claim subsequently submitted for healthcare services specifically included in a prior authorization unless at least one of the following circumstances applies for each healthcare service denied: (1) Benefit limitations, such as annual maximums and frequency limitations not applicable at the time of prior authorization, have been reached due to utilization subsequent to the issuance of the prior authorization, and the health insurance issuer provides notification to the provider prior to healthcare services being rendered. (2) The documentation for the claim provided by the provider clearly fails to support the claim as originally certified. (3) If, subsequent to the issuance of the prior authorization, new services are provided to the enrollee or a change in the enrollee's condition occurs indicating that the prior authorized service would no longer be considered medically necessary, based on the prevailing standard of care. (4) If, subsequent to the issuance of the prior authorization, new services are provided to the enrollee or a change in the enrollee's condition occurs indicating that the prior authorized service would, at that time, require disapproval in accordance with the terms and conditions for coverage under the enrollee's plan in effect at the time the prior authorization was certified. (5) The health insurance issuer's denial is due to one of the following: (a) Another payor is responsible for the payment. (b) The healthcare provider has already been paid for the healthcare services identified on the claim. (c) The claim was submitted fraudulently or the prior authorization was based in whole or material part on erroneous information provided to the health insurance issuer by the healthcare provider, enrollee, or the enrollee's representative. (d) The person receiving the service was not eligible to receive the healthcare service on the date of service, and the health insurance issuer did not know and, with the exercise of reasonable care, could not have known of the person's ineligibility status. B. A health insurance issuer's certification of prior authorization is valid for a minimum of three months.