Adds to exsiting law to establish the Idaho Prior Authorization Refom Act.

LEGISLATURE OF THE STATE OF IDAHO Sixty-eighth Legislature Second Regular Session - 2026 IN THE HOUSE OF REPRESENTATIVES HOUSE BILL NO. 611 BY HEALTH AND WELFARE COMMITTEE AN ACT1 RELATING TO HEALTH INSURANCE; AMENDING TITLE 41, IDAHO CODE, BY THE ADDITION2 OF A NEW CHAPTER 35, TITLE 41, IDAHO CODE, TO ESTABLISH THE IDAHO PRIOR3 AUTHORIZATION REFORM ACT, TO PROVIDE A SHORT TITLE, TO PROVIDE THE PUR-4 POSE OF THE CHAPTER, TO DEFINE TERMS, TO PROVIDE FOR DISCLOSURE AND RE-5 VIEW OF PRIOR AUTHORIZATION REQUIREMENTS, TO PROVIDE FOR STANDARDIZED6 ELECTRONIC PRIOR AUTHORIZATIONS, TO PROVIDE FOR STANDARD PRIOR AUTHO-7 RIZATIONS, TO PROVIDE FOR EXPEDITED PRIOR AUTHORIZATIONS, TO PROVIDE8 FOR NOTIFICATIONS FOR ADVERSE DETERMINATIONS, TO PROVIDE FOR PERSON-9 NEL QUALIFIED TO REVIEW APPEALS, TO PROVIDE FOR INSURER REVIEW OF PRIOR10 AUTHORIZATION REQUIREMENTS, TO PROVIDE FOR REVOCATION OF PRIOR AUTHO-11 RIZATIONS, TO PROVIDE FOR THE LENGTH OF APPROVALS, TO PROVIDE FOR AP-12 PROVALS FOR CHRONIC CONDITIONS, TO PROVIDE FOR CONTINUITY OF PRIOR AP-13 PROVALS, TO PROVIDE FOR THE EFFECT OF AN INSURER'S FAILURE TO COMPLY,14 TO PROVIDE FOR ENFORCEMENT AND ADMINISTRATION, TO PROVIDE FOR REPORTS15 TO THE DEPARTMENT OF INSURANCE, TO PROVIDE FOR FALSE REQUESTS FOR PRIOR16 AUTHORIZATION, AND TO PROVIDE RULEMAKING AUTHORITY; AND DECLARING AN17 EMERGENCY AND PROVIDING AN EFFECTIVE DATE.18

Be It Enacted by the Legislature of the State of Idaho:19

SECTION 1. That Title 41, Idaho Code, be, and the same is hereby amended20 by the addition thereto of a NEW CHAPTER, to be known and designated as Chap-21 ter 35, Title 41, Idaho Code, and to read as follows:22 CHAPTER 3523 IDAHO PRIOR AUTHORIZATION REFORM24 41-3501. SHORT TITLE. This chapter shall be known and may be cited as25 the "Idaho Prior Authorization Reform Act."26 41-3502. PURPOSE. The purpose of this chapter is to:27 (1) Protect the health care provider-patient relationship from unrea-28 sonable third-party interference;29 (2) Prevent prior authorization programs from hindering the indepen-30 dent medical judgment of a physician or other health care provider; and31 (3) Ensure the transparency of a fair and consistent process for health32 care providers and their patients.33 41-3503. APPLICABILITY AND SCOPE. This chapter applies to every34 health benefit plan, as defined in section 41-5903, Idaho Code, to all35 issuers of health benefit plans, and to all utilization reviews and utiliza-36 tion review organizations, as defined in section 41-5903, Idaho Code, except37 for employee or employer self-insured health benefit plans under the fed-38 eral employee retirement income security act of 1974 or health care provided39

2 pursuant to worker's compensation law. This chapter does not diminish the1 duties and responsibilities under other federal or state law or rules pro-2 mulgated under those laws applicable to a health insurer, health insurance3 issuer, health benefit plan, utilization review plan, or utilization review4 organization.5 41-3504. DEFINITIONS. For the purposes of this chapter:6 (1) "Adverse determination" means a determination by a health insur-7 ance issuer that, based on the information provided, a pre-service request8 for a benefit under the health insurance issuer's health benefit plan upon9 application of any utilization review technique does not meet the health10 insurance issuer's requirements for medical necessity, appropriateness,11 health care setting, level of care, or effectiveness or is determined to be12 experimental or investigational, and the requested benefit is therefore13 denied.14 (2) "Appeal" means a formal request, either orally or in writing, to re-15 consider an adverse determination.16 (3) "Approval" means a determination by a health insurance issuer that17 a health care service has been reviewed and, based on the information pro-18 vided, satisfies the health insurance issuer's requirements for medical ne-19 cessity and appropriateness.20 (4) "Clinical review criteria" means the written screening procedures,21 decision abstracts, clinical protocols, and practice guidelines used by a22 health insurance issuer to determine the necessity and appropriateness of23 health care services.24 (5) "Department" means the Idaho department of insurance.25 (6) "Emergency medical condition" means a medical condition manifest-26 ing itself by acute symptoms of sufficient severity, including but not lim-27 ited to severe pain, such that a prudent layperson who possesses an average28 knowledge of health and medicine could reasonably expect the absence of im-29 mediate medical attention to result in:30 (a) Placing the health of the individual or, with respect to a pregnant31 woman, the health of the woman or her unborn child, in serious jeopardy;32 (b) Serious impairment to bodily functions; or33 (c) Serious dysfunction of any bodily organ or part.34 (7) "Emergency services" means health care items and services fur-35 nished or required to evaluate and treat an emergency medical condition.36 (8) "Enrollee" means any person and the person's dependents enrolled in37 or covered by a health care plan.38 (9)(a) "Expedited prior authorization request" means a pre-service or39 concurrent care claim for medical care or treatment for which applica-40 tion of the time periods for making a non-expedited prior authorization41 could, in the opinion of a treating health care professional or health42 care provider with knowledge of the enrollee's medical condition:43 (i) Seriously jeopardize the life or health of the enrollee or the44 ability of the enrollee to regain maximum function;45 (ii) Subject the enrollee to severe pain that cannot be adequately46 managed without the care or treatment that is the subject of the47 authorization request; or48

3 (iii) Lead to likely onset of an emergency medical condition if the1 service is not rendered during the time period to render a prior2 authorization determination for an urgent medical service.3 (b) "Expedited prior authorization request" does not apply to emer-4 gency services.5 (10) "Health care professional" means a physician, a registered profes-6 sional nurse, or another individual appropriately licensed or registered to7 provide health care services.8 (11) "Health care provider" means any physician, hospital, ambulatory9 surgery center, or other person or facility that is licensed or otherwise au-10 thorized to deliver health care services.11 (12) "Health care service" means any services or level of services12 included in the furnishing of medical care to an individual or the hospital-13 ization incident to the furnishing of such care, as well as the furnishing of14 any other services to any person for the purpose of preventing, alleviating,15 curing, or healing human illness or injury, including behavioral health,16 mental health, home health, and pharmaceutical services, products, and med-17 ications.18 (13) "Health insurance issuer" means the issuer of a health benefit19 plan.20 (14) "Medically necessary" means care that a health care professional21 exercising prudent clinical judgment would provide to a patient for the pur-22 pose of preventing, diagnosing, or treating an illness, injury, disease, or23 its symptoms and that is:24 (a) In accordance with generally accepted standards of medical prac-25 tice;26 (b) Clinically appropriate in terms of type, frequency, extent, site,27 and duration and considered effective for the patient's illness, in-28 jury, or disease;29 (c) Focused on what is best for the patient's health outcome; and30 (d) Not primarily for the convenience of the patient, treating physi-31 cian, other health care professional, caregiver, family member, or32 other interested party.33 (15) "NCPDP SCRIPT standard" means the national council for prescrip-34 tion drug programs SCRIPT standard version 2017071, or the most recent stan-35 dard adopted by the United States department of health and human services.36 Subsequently released versions of the NCPDP SCRIPT standard may be used.37 (16) "Physician" means any person with a valid doctor of medicine, doc-38 tor of osteopathy, or doctor of podiatry degree.39 (17) "Prior authorization" means the process by which a health insur-40 ance issuer determines the medical necessity and medical appropriateness of41 an otherwise covered health care service before the rendering of such health42 care service. While not requiring explicit approval, any notification re-43 quired of an enrollee, health care professional, or health care provider by44 the health insurance issuer before, at the time of, or concurrent to provid-45 ing a health care service shall be included within the definition of "prior46 authorization."47 (18) "Utilization review organization" has the meaning given to that48 term in section 41-5903, Idaho Code.49

4 41-3505. DISCLOSURE AND REVIEW OF PRIOR AUTHORIZATION REQUIRE-1 MENTS. (1) A health insurance issuer shall maintain a complete list of2 services for which prior authorization is required, including for all ser-3 vices where prior authorization is performed by an entity under contract4 with the health insurance issuer.5 (2) A health insurance issuer shall make any current prior authoriza-6 tion requirements and restrictions, including the written clinical review7 criteria, readily accessible and conspicuously posted on its website or8 online portal to enrollees, health care professionals, and health care9 providers. Content published by a third party and licensed for use by a10 health insurance issuer may be made available through the health insurance11 issuer's secure, password-protected website or online portal as long as the12 access requirements of the website do not unreasonably restrict access.13 Requirements shall be described in detail, written in easily understandable14 language, and readily available to the health care professional and health15 care provider at the point of care. The website or online portal shall indi-16 cate for each service subject to prior authorization:17 (a) The date on which prior authorization became required for policies18 issued or health benefit plan documents delivered in Idaho, including19 the effective dates and the termination dates, if applicable, in Idaho;20 (b) The date on which the Idaho-specific requirement was listed on the21 website or online portal of the health insurance issuer;22 (c) If applicable, the date on which prior authorization requirement23 was removed for Idaho; and24 (d) If applicable, access to a standardized electronic prior autho-25 rization request transaction process.26 (3) The clinical review criteria must:27 (a) Be consistent with nationally accepted standards generally recog-28 nized by physicians and health care providers practicing in relevant29 medical and clinical specialties except where state law provides its30 own standard;31 (b) Be developed in accordance with the current standards of a national32 medical accreditation entity;33 (c) Ensure quality of care and access to needed health care services;34 (d) Be evidence-based on sources, including peer-reviewed scientific35 studies;36 (e) Be sufficiently flexible to allow deviations from norms when justi-37 fied on a case-by-case basis; and38 (f) Be evaluated and updated under the direction of a physician li-39 censed in the relevant specialty at least annually.40 (4) A health insurance issuer shall not deny a claim for failure to ob-41 tain prior authorization if the prior authorization requirement was not in42 effect on the date of service or if the claim or prior authorization require-43 ments were not publicly disclosed by the plan on the health insurance is-44 suer's website, online portal, or other materials.45 (5) A health insurance issuer shall not deem as incidental or deny sup-46 plies or health care services that are routinely used as part of a health care47 service when:48 (a) An associated health care service has received prior authoriza-49 tion; or50

5 (b) Prior authorization for the health care service is not required.1 (6) If a health insurance issuer intends either to implement a new prior2 authorization requirement or restriction or to amend an existing require-3 ment or restriction, the health insurance issuer shall provide impacted4 enrollees, contracted health care professionals, and contracted health care5 providers of enrollees written notice of the new or amended requirement no6 less than sixty (60) days before the requirement or restriction is imple-7 mented. Written notice may take the form of a conspicuous notice posted on8 the health insurance issuer's public website or online portal for contracted9 health care professionals and contracted health care providers or email no-10 tice to health care professionals or providers. A health insurance issuer11 shall provide email notices to all impacted enrollees and to health care12 professionals or health care providers if the health care professional or13 health care provider has requested to receive the notice through email. A14 new or amended requirement shall not be implemented unless the health insur-15 ance issuer's website or online portal has been updated to reflect the new16 or amended requirement or restriction. Written notice of a new, amended, or17 restricted prior authorization requirement may be provided less than sixty18 (60) days in advance of implementation if a health insurance issuer deter-19 mines and contemporaneously notifies the department in writing that:20 (a) The health insurance issuer has identified fraudulent or abusive21 practices related to the health care service;22 (b) The health care service is unavailable or scarce, necessitating the23 use of an alternative health care service;24 (c) The health care service is newly introduced to the health care mar-25 ket and a delay in providing coverage for the health care service would26 not be in the best interests of enrollees;27 (d) The health care service is the subject of a clinical trial autho-28 rized by the United States food and drug administration;29 (e) Changes to the health care service or its availability are other-30 wise required by law to be made by the health insurance issuer in less31 than sixty (60) days; or32 (f) The prior authorization requirement is being removed.33 (7) Health insurance issuers using prior authorization shall make sta-34 tistics available regarding prior authorization approvals and denials on35 their website or online portal in a readily accessible format. Following36 each calendar year, the statistics shall be updated annually by February 1,37 and include all of the following information:38 (a) A list of all health care services, including medications, that are39 subject to prior authorization;40 (b) The percentage of standard prior authorization requests that were41 approved, aggregated for all items and services;42 (c) The percentage of standard prior authorization requests that were43 denied, aggregated for all items and services;44 (d) The percentage of prior authorization requests that were approved45 after appeal, aggregated for all items and services;46 (e) The percentage of prior authorization requests for which the time47 frame for review was extended, and the request was approved , aggregated48 for all items and services;49

6 (f) The percentage of expedited prior authorization requests that were1 approved, aggregated for all items and services;2 (g) The percentage of expedited prior authorization requests that were3 denied, aggregated for all items and services;4 (h) The average and median time that elapsed between the submission of a5 request and a determination by the health insurance issuer for standard6 prior authorization, aggregated for all items and services; and7 (i) The average and median time that elapsed between the submission of8 a request and a determination by the health insurance issuer for expe-9 dited prior authorization, aggregated for all items and services.10 41-3506. STANDARDIZED ELECTRONIC PRIOR AUTHORIZATIONS. (1) If a11 health insurance issuer requires prior authorization of a health care ser-12 vice, the issuer or its contracted utilization review organization shall,13 by July 1, 2026, make available a standardized electronic prior authoriza-14 tion request transaction process using an internet website, online portal,15 or similar electronic, web-based system. After January 1, 2027, a health16 insurance issuer shall accept and respond to prior authorization requests17 under the pharmacy benefit through a secure electronic transmission using18 the NCPDP SCRIPT standard electronic prior authorization transactions.19 (2) No later than January 1, 2027, all health care professionals and20 health care providers shall be required to use the standardized electronic21 prior authorization request transaction process made available as required22 by subsection (1) of this section.23 (3) For purposes of this chapter, a prior authorization request shall24 be considered received upon:25 (a) Confirmation of electronic submission; or26 (b) The next calendar day following submission if submitted outside of27 normal business hours.28 41-3507. STANDARD PRIOR AUTHORIZATIONS. If a health insurance issuer29 requires prior authorization of a health care service, the health insurance30 issuer shall make an approval or adverse determination and notify the en-31 rollee and the enrollee's health care professional or health care provider32 of the approval or adverse determination as expeditiously as the enrollee's33 condition requires but no later than five (5) calendar days after obtaining34 all necessary information to make the approval or adverse determination,35 unless a longer minimum time frame is required under federal law for the36 health insurance issuer and the health care service at issue. Requests for37 information must be reasonably necessary to adjudicate the prior authoriza-38 tion request. As used in this section, "necessary information" includes the39 results of any face-to-face clinical evaluation, second opinion, or other40 clinical information that is directly applicable to the requested service41 that may be required. Provided, however, health insurance issuers shall42 respond within two (2) business days for prior authorization requests for43 pharmaceutical services and products.44 41-3508. EXPEDITED PRIOR AUTHORIZATIONS. (1) If requested by a treat-45 ing health care professional or health care provider for an enrollee, a46 health insurance issuer shall render an approval or adverse determination47

7 concerning urgent health care services and notify the enrollee and the en-1 rollee's health care professional or health care provider of that approval2 or adverse determination as expeditiously as the enrollee's condition3 requires but no later than twenty-four (24) hours after receiving all infor-4 mation needed to complete the review of the requested health care services5 unless a longer minimum time frame is required under federal law for the6 health insurance issuer and the urgent health care service at issue.7 (2) To facilitate the rendering of a prior authorization determina-8 tion pursuant to this section, a health insurance issuer shall establish a9 mechanism to ensure health care professionals have access to appropriately10 trained and licensed physicians of the same specialty for consultation,11 designated by the issuer to make such determinations for prior authorization12 concerning urgent care services.13 41-3509. NOTIFICATIONS FOR ADVERSE DETERMINATIONS. If a health in-14 surance issuer makes an adverse determination, the health insurance issuer15 shall include the following in the notification to the enrollee and the en-16 rollee's health care professional or health care provider:17 (1) The reasons for the adverse determination and related evi-18 dence-based criteria, including a description of any missing or insuffi-19 cient documentation;20 (2) The right to appeal the adverse determination;21 (3) Instructions on how to file the appeal;22 (4) Additional documentation necessary to support the appeal; and23 (5) The right to request an independent external review pursuant to the24 provisions of chapter 59, title 41, Idaho Code.25 41-3510. PERSONNEL QUALIFIED TO REVIEW APPEALS. A health insurance26 issuer shall ensure that all appeals are reviewed by a physician when the27 request is made by a physician or a representative of a physician. The re-28 viewing physician shall:29 (1) Possess a current and valid nonrestricted license to practice30 medicine with substantially similar licensing requirements to this state;31 (2) Be certified by the American board of medical specialties or the32 American osteopathic association within the relevant specialty of a physi-33 cian who typically manages the medical condition or disease;34 (3) Have training, knowledge, or experience of providing the health35 care services under appeal;36 (4) Not have been directly involved in making the adverse determina-37 tion; and38 (5) Consider all known clinical aspects of the health care service un-39 der review, including a review of all pertinent medical records provided to40 the health insurance issuer or health care provider, the health plan's clin-41 ical guidelines, and peer-reviewed scientific studies.42 41-3511. INSURER REVIEW OF PRIOR AUTHORIZATION REQUIREMENTS. A health43 insurance issuer shall periodically review its prior authorization require-44 ments and consider removal of prior authorization requirements.45

8 41-3512. REVOCATION OF PRIOR AUTHORIZATIONS. (1) A health insurance1 issuer may not revoke or further limit, condition, or restrict a previously2 issued prior authorization approval while it remains valid in accordance3 with this chapter unless:4 (a) The health insurance issuer has identified fraudulent or abusive5 practices related to the health care service;6 (b) The health care service is unavailable, necessitating the use of an7 alternative health care service;8 (c) The health care service is the subject of a new safety alert from the9 United States food and drug administration or is in response to a public10 health emergency;11 (d) The change is based on nationally recognized generally accepted12 standards developed in accordance with current standards of a national13 medical accreditation entity or specialty society; or14 (e) Changes to the health care service or its availability are other-15 wise required by law to be made by the health insurance issuer within16 sixty (60) days.17 (2) Notwithstanding any other provision of law, if a claim is properly18 coded and submitted timely to a health insurance issuer, the health insur-19 ance issuer shall make payment according to the terms of coverage on claims20 for health care services for which prior authorization was required and ap-21 proval received before the provision of health care services unless:22 (a) It is determined that the enrollee's health care professional or23 health care provider knowingly and without exercising prudent clinical24 judgment provided health care services that required prior authoriza-25 tion from the health insurance issuer or its contracted utilization re-26 view organization without first obtaining prior authorization for such27 health care services;28 (b) It is timely determined that the health care services claimed were29 not performed;30 (c) It is timely determined that the health care services provided by31 the enrollee's health care provider or health care professional were32 contrary to the instructions of the health insurance issuer or its con-33 tracted utilization review organization if contact was made between34 such parties before the service being provided;35 (d) It is timely determined that the person receiving such health care36 services was not an enrollee of the health care plan; or37 (e) The approval was based on a material misrepresentation by the en-38 rollee, health care professional, or health care provider. As used in39 this paragraph, "material" means a fact or situation that would have re-40 sulted in a substantial change in the determination had it been accu-41 rately disclosed in the submission.42 (3) Nothing in this section shall preclude a utilization review organi-43 zation or a health insurance issuer from performing post-service reviews of44 health care claims for purposes of payment integrity or for the prevention of45 fraud, waste, or abuse.46 41-3513. LENGTH OF APPROVALS. (1) A prior authorization approval47 shall be valid for twelve (12) months after the date the health care profes-48 sional or health care provider receives the prior authorization approval.49

9 Provided, however, a health insurance issuer and an enrollee or enrollee's1 health care professional may extend a prior authorization approval for a2 longer period, by agreement. All dosage increases shall be based on estab-3 lished evidentiary standards, and nothing in this section shall prohibit4 a health insurance issuer from having safety edits in place. This section5 shall not apply to the prescription of benzodiazepines or schedule II nar-6 cotic drugs, such as opioids.7 (2) Nothing in this section shall require a policy or plan to cover any8 care, treatment, or services for any health condition that the terms of cov-9 erage otherwise completely exclude from the policy's or plan's covered ben-10 efits without regard for whether the care, treatment, or services are medi-11 cally necessary.12 41-3514. APPROVALS FOR CHRONIC CONDITIONS. (1) If a health insurance13 issuer requires a prior authorization for a recurring health care service14 or maintenance medication for the treatment of a chronic or long-term condi-15 tion, including but not limited to chemotherapy for the treatment of cancer,16 the approval shall remain valid for the lesser of twelve (12) months from the17 date the health care professional or health care provider receives the au-18 thorization approval or the length of the treatment as determined by the pa-19 tient's health care professional. Provided, however, a health insurance is-20 suer and an enrollee or the enrollee's health care professional may extend a21 prior authorization approval for a longer period, by agreement. This sec-22 tion shall not apply to the prescription of benzodiazepines or schedule II23 narcotic drugs, such as opioids.24 (2) Nothing in this section shall require a policy or plan to cover any25 care, treatment, or services for any health condition that the terms of cov-26 erage otherwise completely exclude from the policy's or plan's covered ben-27 efits without regard for whether the care, treatment, or services are medi-28 cally necessary.29 41-3515. CONTINUITY OF PRIOR APPROVALS. (1) Upon receipt of informa-30 tion documenting a prior authorization approval from the enrollee or from31 the enrollee's health care professional or health care provider, a health32 insurance issuer shall honor a prior authorization granted to an enrollee33 from a previous health insurance issuer for at least the initial ninety (90)34 days of an enrollee's coverage under a new health plan, subject to the terms35 of the enrollee's coverage agreement.36 (2) During the time period described in subsection (1) of this section,37 a health insurance issuer may perform its own review to grant a prior autho-38 rization approval, subject to the terms of the enrollee's coverage agree-39 ment.40 (3) If there is a change in coverage of or approval criteria for a pre-41 viously authorized health care service, the change in coverage or approval42 criteria does not affect an enrollee who received prior authorization before43 the effective date of the change for the remainder of the enrollee's plan44 year.45 (4) Except to the extent required by medical exceptions processes for46 prescription drugs, nothing in this section shall require a policy or plan47 to cover any care, treatment, or services for any health condition that the48

10 terms of coverage otherwise completely exclude from the policy's or plan's1 covered benefits without regard for whether the care, treatment, or services2 are medically necessary.3 41-3516. EFFECT OF INSURER'S FAILURE TO COMPLY. A failure by a health4 insurance issuer to comply with the deadlines and other requirements speci-5 fied in this chapter shall result in any health care services subject to re-6 view to be automatically deemed authorized by the health insurance issuer or7 its contracted utilization review organization.8 41-3517. ENFORCEMENT AND ADMINISTRATION. (1) In addition to the en-9 forcement powers granted to it by law to enforce the provisions of this chap-10 ter, the department is granted specific authority to issue a cease-and-de-11 sist order or require a utilization review organization or health insurance12 issuer, or both, to submit a plan of correction for violations of this chap-13 ter. Subject to rules promulgated by the department pursuant to chapter 52,14 title 67, Idaho Code, and after proper notice and the opportunity for a hear-15 ing, the department may impose on a utilization review organization, health16 benefit plan, or health insurance issuer an administrative fine not to ex-17 ceed ten thousand dollars ($10,000) per violation for failure to submit a re-18 quested plan of correction, failure to comply with its plan of correction,19 or repeated violations of this chapter. All fines collected by the depart-20 ment pursuant to this section shall be deposited in the state general fund.21 The department may also exercise all authority granted to it under the pro-22 visions of chapter 59, title 41, Idaho Code, to deny or revoke approval of a23 utilization review organization for a violation of this chapter.24 (2) An enrollee or an enrollee's health care provider who has evidence25 that the enrollee's health insurance issuer or health benefit plan is in26 violation of the provisions of this chapter may file a complaint with the27 department. The department shall review all complaints received and in-28 vestigate all complaints that it deems to state a potential violation. The29 department shall fairly, efficiently, and timely review and investigate30 complaints and shall provide the subject of the complaint an opportunity to31 refute the evidence against it. Health insurance issuers, health benefit32 plans, and utilization review organizations found to be in violation of this33 chapter shall be penalized in accordance with this section.34 (3) There shall be no private right of action under this chapter.35 41-3518. REPORTS TO THE DEPARTMENT. (1) By June 1, 2027, and each June36 1 thereafter, a health insurance issuer shall report to the department, on a37 form issued by the department, the following aggregated trend data, de-iden-38 tified of protected health information, related to the insurer's practices39 and experience for the prior plan year for health care services submitted for40 payment:41 (a) The number of prior authorization requests;42 (b) The percentage of prior authorization requests denied;43 (c) The percentage of prior authorization appeals received;44 (d) The percentage of adverse determinations reversed on appeal;45 (e) The percentage of prior authorization requests that were not sub-46 mitted electronically;47

11 (f) As a percentage by service, the ten (10) health care services that1 were most frequently denied through prior authorization; and2 (g) The five (5) reasons prior authorization requests were most fre-3 quently denied.4 (2) All reports required by this section shall be considered public5 records pursuant to chapter 1, title 74, Idaho Code, and the department shall6 make all reports freely available to requestors and post all reports to its7 public website without redactions.8 41-3519. FALSE REQUESTS FOR PRIOR AUTHORIZATION. If a health insur-9 ance issuer has clear and convincing evidence that a health care profes-10 sional or health care provider has knowingly and willfully submitted false11 or fraudulent requests for prior authorization to the health insurance is-12 suer, the issuer shall notify and provide that information to the department13 director. After receipt of such notification and information, the director14 shall forward these reports to the board of medicine or such other licensing15 agency with oversight of the health care provider and to the office of the16 prosecuting authority having jurisdiction.17 41-3520. RULES. The department shall have the authority to promulgate18 rules, subject to legislative approval, pursuant to the provisions of chap-19 ter 52, title 67, Idaho Code, to govern the administration of this chapter.20

SECTION 2. An emergency existing therefor, which emergency is hereby21 declared to exist, this act shall be in full force and effect on and after22 July 1, 2026.23