215 Ill. Comp. Stat. §§ 180/1 through 180/42: Health Carrier External Review Act – Illinois
Status: Enacted Year Enacted: 2010
The Health Carrier External Review Act’s purpose is to provide uniform standards for the establishment and maintenance of external review procedures. Statutes set out timeline and process for a standard review.
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27 R.I. Gen. Laws § 27-18-76. Emergency services: Accident and Sickness Insurance Policies – Rhode Island
Status: Enacted Year Enacted: 2012
If a nonprofit medical service corporation offering health insurance coverage provides any benefits with respect to services in an emergency department of a hospital, it must cover emergency services consistent with the rules of this …
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27 R.I. Gen. Laws § 27-19-66. Emergency services: Nonprofit Hospital Service Corporations – Rhode Island
Status: Enacted Year Enacted: 2012
If a nonprofit medical service corporation offering health insurance coverage provides any benefits with respect to services in an emergency department of a hospital, it must cover emergency services consistent with the rules of this …
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27 R.I. Gen. Laws § 27-20-1. Definitions: Nonprofit Medical Service Corporations – Rhode Island
Status: Enacted Year Enacted: 1945
Definitions related to Nonprofit Medical Service Corporations
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27 R.I. Gen. Laws § 27-20-62. Emergency services: Nonprofit Medical Service Corporations – Rhode Island
Status: Enacted Year Enacted: 2012
If a nonprofit medical service corporation offering health insurance coverage provides any benefits with respect to services in an emergency department of a hospital, it must cover emergency services consistent with the rules of this …
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305 Ill. Comp. Stat. § 5/5-30.1. Managed care protections: Medical Assistance – Illinois
Status: Enacted Year Enacted: 2014
An MCO shall pay any provider of emergency services that does not have in effect a contract with the contracted Medicaid MCO. The default rate of reimbursement shall be the rate paid under Illinois Medicaid …
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305 Ill. Comp. Stat. § 5/5-5f. Elimination and limitations of medical assistance services: Medical Assistance – Illinois
Status: Enacted Year Enacted: 2012
Statute requires prior approval for certain services and requires the Department to establish benchmarks for hospitals to measure and align payments to reduce potentially preventable hospital readmissions, complications and unnecessary emergency room visits.
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40 Pa. Cons. Stat. § 991.2152. Operations standards: Utilization Review – Pennsylvania
Status: Enacted Year Enacted: 1998
Outlines requirements for an entity to perform utilization review.
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40 Pa. Cons. Stat. § 991.2162. External grievance process: Quality Health Care Accountability and Protection – Pennsylvania
Status: Enacted Year Enacted: 1998
A managed care plan shall establish and maintain an external grievance process by which an enrollee or a health care provider with the written consent of the enrollee may appeal the denial of a grievance …
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62 Pa. Stat. and Cons. Stat. Ann. § 443.6. Reimbursement for certain medical assistance items and services: Human Services Code — Medical Assistance – Pennsylvania
Status: Enacted Year Enacted: 1978
In order to receive reimbursement for items or services enumerated in subsection (b), the provider must secure authorization prior to actually providing the items or services. The request for prior authorization must justify to the …
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63 Pa. Cons. Stat. § 390-8. Unlawful acts: Pharmacy Acts – Pennsylvania
Status: Enacted Year Enacted: 1961
It shall be unlawful for any pharmacist to dispense an emergency prescription, unless the pharmacist does the specified. For example, the pharmacist must first attempt to obtain an authorization from the authorized prescriber and cannot …
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A 03038 (see companion bill S 02847) – New York
Introduced: 2019 Status: Inactive / Dead
Relates to utilization review program standards; requires use of evidence-based and peer reviewed clinical review criteria; amends provisions relating to prescription drug formulary changes and pre-authorization for certain health care services.
A 04103 – New York
Introduced: 2019 Status: Inactive / Dead
Directs a health maintenance organization which denies claim due to absence of medical necessity to inform insured as to preferred alternative treatment, or provide the insured with a statement as to the past ineffectiveness of …
A 04521 – New York
Introduced: 2019 Status: Inactive / Dead
Relates to access to appropriate drugs at reasonable prices, formulary exceptions, standing prior authorizations and external appeals; to access to retail pharmacies, prescription synchronization, limits on patient drug costs, explanations of benefits and rebates; to …
A 1255 (see companion bill S 1794) – New Jersey
Introduced: 2022 Status: In Process
“Ensuring Transparency in Prior Authorization Act.” This bill places certain requirements regarding the use of prior authorization of health benefits on carriers and utilization review entities acting on behalf of carriers. The bill requires a …
A 1972 (see companion bill S 1850) – New Jersey
Introduced: 2020 Status: Inactive / Dead
“Ensuring Transparency in Prior Authorization Act.” The bill requires a utilization review entity to make certain disclosures regarding its prior authorization requirements and restrictions, on its website and in writing, including certain statistics concerning approvals …