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2017 Arkansas Code
Title 23 - Public Utilities and Regulated Industries
Subtitle 3 - Insurance
Chapter 99 - Healthcare Providers
Subchapter 11 - Prior Authorization Transparency Act
§ 23-99-1113. Benefit inquiries authorized
Universal Citation: AR Code § 23-99-1113 (2017)
- (a)
- (1) An in-network or out-of-network healthcare provider may submit a benefit inquiry to a healthcare insurer or utilization review entity for a healthcare service not yet provided to determine whether or not the healthcare service meets medical necessity and all other requirements for payment under a health benefit plan if the healthcare service were to be provided to a specific subscriber.
- (2)
- (A) The State Insurance Department shall issue a rule on or before January 1, 2018, that defines which benefits are subject to the requirements of this section.
- (B) Until a rule is promulgated under subdivision (a)(2)(A) of this section, all benefit inquiries shall be processed according to this section.
- (b) If a healthcare insurer or utilization review entity lacks sufficient information to respond to a benefit inquiry, the healthcare insurer or utilization review entity shall notify the healthcare provider within two (2) business days of the additional information that is required to respond to the benefit inquiry.
- (c)
- (1) A healthcare insurer, either directly or through a utilization review entity, shall respond to a benefit inquiry authorized in subsection (a) of this section within ten (10) business days of receipt of information required to make a decision on the benefit inquiry.
- (2) Responses to a benefit inquiry shall be provided in the same form and manner as responses to requests for prior authorization.
- (d) Every healthcare insurer shall provide a convenient and accessible procedure for healthcare providers to submit benefit inquiries under this section.
- (e) Sections 23-99-1109 -- 23-99-1111 and 23-99-1114 -- 23-99-1116 apply to the benefit inquiry process of any healthcare insurer or utilization review entity.
- (f) A healthcare service approved under the benefit inquiry process authorized in this section is not subject to audit recoupment under § 23-63-1801 et seq., except as provided for in § 23-99-1109(b).
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