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ARIZONA HOUSE OF REPRESENTATIVES57th Legislature, 2nd Regular Session |
House: HHS DPA/SE 12-0-0-0 |
HB 2182: emergency medical services; patient transport
S/E: reporting; prior authorization; claims denial
Sponsor: Representative Willoughby, LD 13
Caucus & COW
Summary of the Strike-Everything Amendment to HB 2182
Overview
Establishes reporting requirements for the Department of Insurance and Financial Institutions (DIFI) relating to claim denial practices and prior authorization practices. Requires DIFI, by July 1, 2032, to hold a stakeholder meeting to evaluate the usefulness of the collected data.
History
A claim is a request for payment for an already provided diagnostic or therapeutic medical or health care service, benefit or treatment. Statute prescribes and governs the health care appeal process for members whose claim for a service has been denied by an insurer (A.R.S. §§ 20-2501 and 20-2531).
Grievances are any written complaint that is subject to resolution through the insurer's internal system for resolving payment disputes and other contractual grievances with health care providers and submitted by a health care provider and received by the health care insurer. Grievances do not include: 1) complaints by a noncontracted provider regarding an insurer's decision to deny the noncontracted provider admission to the insurer's network; 2) complaints about an insurer's decision to terminate a health care provider from the insurer's network; and 3) complaints that are subject of a health care appeal. Health care insurers are required to establish an internal system for resolving payment disputes and other contractual grievances with health care providers. Each health care insurer must provide a summary of all records of health care provider grievances received during the prior six months. The Director of DIFI may review the health care insurer's internal system and examine the health care insurer if it find's a significant number of grievances that have not been resolved (A.R.S. §§ 20-3101 and 20-3102).
A prior authorization requirement is a practice implemented by a health care services plan, or its utilization review agent, in which coverage of a health care service is dependent on an approval from the health care services plan before the service is performed, received or prescribed. It includes preadmission review, pretreatment review, prospective review or utilization review procedures conducted by a health care services plan or its utilization review agent before providing a health care service and does not include case management or step therapy protocols (A.R.S. § 20-3401).
Provisions
Claim Denial Practices Reporting Requirements
1. Requires a health care insurer, by July 1, 2027, and annually thereafter, to report to DIFI the following aggregated data that relates to the health care insurer's claims denial practices for the prior plan year:
a. the total number of claims requests, including the total number of claims requests that were not submitted electronically;
b. the total number of claims requests that were denied;
c. the total number of appeals that were received;
d. the total number of adverse determinations that were reversed on appeal; and
e. the top five reasons why claims requests were denied. (Sec. 1)
Prior Authorization Practices Reporting Requirements
2. Requires a health care insurer, by July 1, 2027, and annually thereafter, to report to DIFI the following aggregated data that relates to the health care insurer's prior authorization practices for the prior plan year:
a. the total number of prior authorization requests, including the total number of prior authorization requests that were not submitted electronically;
b. the total number of prior authorization requests that were denied;
c. the total number of appeals that were received;
d. the total number of adverse determinations that were reversed on appeal;
e. the top five reasons why prior authorization requests were denied;
f. the average and median time that elapsed between the submission of a prior authorization request and a determination by the issuer for standard prior authorizations;
g. the average and median time that elapsed between the submission of a prior authorization request and a determination by the issuer for expedited prior authorizations. (Sec. 3)
DIFI
3. Requires DIFI, by October 31, 2027, and each October 1 after, to aggregate the data for both reports and:
a. separate each health care insurer that submitted data by name and write it in easily understandable language;
b. post the reports on its publicly accessible website; and
c. send a copy of the reports to the Speaker of the Arizona House of Representatives and the President of the Senate. (Sec 1)
4. Requires DIFI, by July 1, 2032, to convene a stakeholder meeting to determine the quality, relevance usefulness of the collected data. (Sec. 4)
5. Requires the stakeholders meeting to include:
a. health care insurers;
b. health care services plans;
c. licensed health care providers;
d. businesses and consumers; and
e. health care institutions that are regulated by the Department of Health Services. (Sec. 4)
6. Requires DIFI, by October 31, 2032, to submit a report to the Governor, President of the Senate and Speaker of the Arizona House of Representatives with recommendations to amend, repeal or to make no change changes to the collected data. (Sec. 4)
7. Requires DIFI to maintain at least three years of the reports on its publicly accessible website. (Sec 1 and 3)
8. Changes the date DIFI is required to post on its website information on grievances for the prior fiscal year from annually on August 1 to October 1. (Sec. 2)
Miscellaneous
9. Requires a health care insurer to include in both reports the top 10 services that were denied in each of the following categories:
a. medical and surgical procedures;
b. diagnostic tests and images;
c. behavioral health services;
d. orthopedic services; and
e. outpatient services. (Sec. 1 and 3)
10. Makes the legislation retroactive to July 1, 2026. (Sec. 5)
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14. Initials AG HB 2182
15. 2/13/2026 Page 0 Caucus & COW
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