Current through Reg. 50, No. 187; September 24, 2024
(1) Scope: This rule applies to all insurance
companies, health maintenance organizations, and managed care entities
authorized to write health insurance in Florida.
(2) Definitions: As used in this rule:
(a) "Health Insurer" means an authorized
insurer offering health insurance as defined in Section
624.603, F.S., a managed care
plan as defined in Section
409.962(9),
F.S., or a health maintenance organization as defined in Section
641.19(12)
F.S.
(b) "Utilization review
entity" means any person that performs prior authorization for a health
insurer.
(c) "Person" has the same
meaning as defined in Section
624.04, F.S.
(d) "Prior authorization" means any practice
implemented by a health insurer or a health insurer's utilization review entity
in which coverage of a health care service, device, or drug is dependent upon a
covered person or health care practitioner obtaining approval from the health
insurer or utilization review entity prior to the service, device, or drug
being performed, received, or prescribed, as applicable. "Prior authorization"
includes prospective or utilization review procedures conducted prior to
providing a health care service, device, or drug.
(3) All prior authorization forms must
provide for the following information:
(a)
Sufficient information to identify the covered person, including the covered
person's date of birth, full name, and health plan identification
number.
(b) Sufficient information
to identify the ordering provider, including the provider's name, National
Provider Identification number, and the provider's contact
information.
(c) Sufficient
information to identify the rendering provider, including the name of the
rendering provider, provider group, or facility, corresponding National
Provider Identification number, and the rendering provider's contact
information.
(d) Sufficient
information to identify and contact the rendering facility, if different from
subparagraph c.
(e) Where the
service or procedure will be performed if different from subparagraph c. or
d.
(f) The health care service
being requested, including the medical reason therefore.
(g) The unit or volume of the procedure,
service, or device being requested when applicable.
(h) All services tried and shown to be
ineffective.
(i) A list of any
additional documentation required by the health insurer or utilization review
entity to complete its review of the prior authorization request, and any other
information necessary to facilitate the determination of the medical necessity
of the requested procedure, course of treatment or prescription drug
benefit.
(j) The priority of the
prior authorization request. At a minimum, the prior authorization form shall
contain the following designations:
1.
Standard.
2. Date of Service, which
should include a space for the planned date of a service.
3. Urgent or Emergency, to be used when the
provider certifies that applying the standard review time frame may seriously
jeopardize the life or health of the patient.
(k) The latest International Classification
of Disease primary diagnosis code.
(l) An attestation or certification that all
information provided is true and accurate.
(4) All prior authorization forms must
contain information where a provider may find a health insurer's list of
services subject to prior authorization.
(5) The prior authorization form must contain
the direct contact information for the health insurer.
(6) The prior authorization form may not
require information that is not needed to make a determination or facilitate a
determination of medical necessity of the requested medical procedure, course
of treatment, or prescription drug benefit.
(7) Disclosure and review of prior
authorization requirements. A health insurer shall make any current prior
authorization forms, directions as to when to use such forms, and instructions
for filling out such forms, readily accessible on its website and in written
form upon request for beneficiaries and health care
providers.
Rulemaking Authority 624.308(1), 627.42392 FS. Law
Implemented 624.307(1), 627.42392 FS.
New 1-11-17.
