Adds to existing law to establish the Idaho Prior Authorization Reform Act.

LEGISLATURE OF THE STATE OF IDAHO Sixty-eighth Legislature Second Regular Session - 2026 IN THE HOUSE OF REPRESENTATIVES HOUSE BILL NO. 841 BY WAYS AND MEANS 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 PROVIDE FOR APPLICABILITY AND SCOPE, TO DEFINE5 TERMS, TO PROVIDE FOR DISCLOSURE AND REVIEW OF PRIOR AUTHORIZATION RE-6 QUIREMENTS, TO PROVIDE FOR PRIOR AUTHORIZATION APPLICATION PROGRAMMING7 INTERFACE, TO PROVIDE FOR STANDARD PRIOR AUTHORIZATIONS, TO PROVIDE8 FOR EXPEDITED PRIOR AUTHORIZATIONS, TO PROVIDE FOR NOTIFICATIONS FOR9 ADVERSE DETERMINATIONS, TO PROVIDE FOR PERSONNEL QUALIFIED TO REVIEW10 APPEALS, TO PROVIDE FOR INSURER REVIEW OF PRIOR AUTHORIZATION REQUIRE-11 MENTS, TO PROVIDE FOR REVOCATION OF PRIOR AUTHORIZATIONS, TO PROVIDE12 FOR THE LENGTH OF APPROVALS, TO PROVIDE FOR APPROVALS FOR CHRONIC CONDI-13 TIONS, TO PROVIDE FOR CONTINUITY OF PRIOR APPROVALS, TO PROVIDE FOR EN-14 FORCEMENT AND ADMINISTRATION, TO PROVIDE FOR REPORTS TO THE DEPARTMENT15 OF INSURANCE, TO PROVIDE FOR FALSE REQUESTS FOR PRIOR AUTHORIZATION, TO16 PROVIDE FOR A DE MINIMIS PRIOR AUTHORIZATION UTILIZATION EXEMPTION, AND17 TO PROVIDE RULEMAKING AUTHORITY; 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 all is-35 suers of health benefit plans, to all incorporated or stand-alone dental36 benefit plans, and to all utilization reviews and utilization review orga-37 nizations, as defined in section 41-5903, Idaho Code, except for employee38 or employer self-insured health benefit plans under the federal employee39

2 retirement income security act of 1974, health care provided pursuant to1 worker's compensation law, or prescription drugs, biologics, biosimilars,2 and pharmaceutical medicines. This chapter does not diminish the duties and3 responsibilities under other federal or state law or rules promulgated under4 those laws applicable to a health insurer, health insurance issuer, health5 benefit plan, utilization review plan, or utilization review organization.6 41-3504. DEFINITIONS. For the purposes of this chapter:7 (1) "Adverse determination" means a determination by a health insur-8 ance issuer that, based on the information provided, a pre-service request9 for a benefit under the health insurance issuer's health benefit plan upon10 application of any utilization review technique does not meet the health11 insurance issuer's requirements for medical necessity, appropriateness,12 health care setting, level of care, or effectiveness or is determined to be13 experimental or investigational, and the requested benefit is therefore14 denied.15 (2) "Appeal" means a formal request, either orally or in writing, to re-16 consider an adverse determination.17 (3) "Approval" means a determination by a health insurance issuer that18 a health care service has been reviewed and, based on the information pro-19 vided, satisfies the health insurance issuer's requirements for medical ne-20 cessity and appropriateness.21 (4) "Clinical review criteria" means the written screening procedures,22 decision abstracts, clinical protocols, and practice guidelines used by a23 health insurance issuer to determine the necessity and appropriateness of24 health care services.25 (5) "Complete prior authorization request" means a prior authorization26 request that:27 (a) Is submitted by a health care professional or health care provider28 in accordance with the standardized electronic prior authorization29 process required by this chapter, if applicable;30 (b) Includes all clinical documentation, diagnostic results, and other31 information reasonably required by the health insurance issuer's pub-32 licly disclosed clinical review criteria in effect at the time the re-33 quest is submitted;34 (c) Requires no additional information from the enrollee, the35 provider, or a third party that is reasonably necessary to adjudicate36 the request; and37 (d) Complies with the health insurance issuer's published prior autho-38 rization submission standards in effect at the time the request is sub-39 mitted.40 (6) "Dentist" means any person with a valid doctor of dental surgery,41 doctor of medicine in dentistry, or doctor of dental medicine degree.42 (7) "Department" means the Idaho department of insurance.43 (8) "Emergency medical condition" means a medical condition manifest-44 ing itself by acute symptoms of sufficient severity, including but not lim-45 ited to severe pain, such that a prudent layperson who possesses an average46 knowledge of health and medicine could reasonably expect the absence of im-47 mediate medical attention to result in:48

3 (a) Placing the health of the individual or, with respect to a pregnant1 woman, the health of the woman or her unborn child, in serious jeopardy;2 (b) Serious impairment to bodily functions; or3 (c) Serious dysfunction of any bodily organ or part.4 (9) "Emergency services" means health care items and services fur-5 nished or required to evaluate and treat an emergency medical condition.6 (10) "Enrollee" means any person and the person's dependents enrolled7 in or covered by a health care plan.8 (11)(a) "Expedited prior authorization request" means a pre-service or9 concurrent care claim for medical care or treatment for which applica-10 tion of the time periods for making a non-expedited prior authorization11 could, in the opinion of a treating health care professional or health12 care provider with knowledge of the enrollee's medical condition:13 (i) Seriously jeopardize the life or health of the enrollee or the14 ability of the enrollee to regain maximum function;15 (ii) Subject the enrollee to severe pain that cannot be adequately16 managed without the care or treatment that is the subject of the17 authorization request; or18 (iii) Lead to likely onset of an emergency medical condition if the19 service is not rendered during the time period to render a prior20 authorization determination for an urgent medical service.21 (b) "Expedited prior authorization request" does not apply to emer-22 gency services.23 (12) "Health care professional" means a physician, a registered pro-24 fessional nurse, a dentist, or another individual appropriately licensed or25 registered to provide health care services.26 (13) "Health care provider" means any physician, dentist, hospital, am-27 bulatory surgery center, or other person or facility that is licensed or oth-28 erwise authorized to deliver health care services.29 (14) "Health care service" means any services or level of services in-30 cluded in the furnishing of medical or dental care to an individual or the31 hospitalization incident to the furnishing of such care, as well as the fur-32 nishing of any other services to any person for the purpose of preventing,33 alleviating, curing, or healing human illness or injury, including behav-34 ioral health, mental health, and home health, and pharmaceutical services,35 products, and medications.36 (15) "Health insurance issuer" means the issuer of a health benefit plan37 or dental benefit plan.38 (16) "Medically necessary" means care that a health care professional39 exercising prudent clinical judgment would provide to a patient for the pur-40 pose of preventing, diagnosing, or treating an illness, injury, disease, or41 its symptoms and that is:42 (a) In accordance with generally accepted standards of medical prac-43 tice or dental practice;44 (b) Clinically appropriate in terms of type, frequency, extent, site,45 and duration and considered effective for the patient's illness, in-46 jury, or disease;47 (c) Focused on what is best for the patient's health outcome; and48

4 (d) Not primarily for the convenience of the patient, treating physi-1 cian, other health care professional, caregiver, family member, or2 other interested party.3 (17) "Physician" means any person with a valid doctor of medicine, doc-4 tor of osteopathy, or doctor of podiatry degree.5 (18) "Prior authorization" means the process by which a health insur-6 ance issuer determines the medical necessity and medical appropriateness of7 an otherwise covered health care service before the rendering of such health8 care service. While not requiring explicit approval, any notification re-9 quired of an enrollee, health care professional, or health care provider by10 the health insurance issuer before, at the time of, or concurrent to provid-11 ing a health care service shall be included within the definition of "prior12 authorization." Any pre-service review that is used to evaluate clinical ne-13 cessity, regardless of the terminology used to describe such pre-service re-14 view, falls within this definition, including but not limited to predetermi-15 nation, pretreatment, and preauthorization.16 (19) "Urgent health care services" means those services that, if not17 provided to an enrollee, could seriously jeopardize the enrollee's life,18 health, or ability to regain maximum function.19 (20) "Utilization review organization" has the meaning given to that20 term in section 41-5903, Idaho Code.21 41-3505. DISCLOSURE AND REVIEW OF PRIOR AUTHORIZATION REQUIRE-22 MENTS. (1) A health insurance issuer shall maintain a complete list of23 services for which prior authorization is required, including for all ser-24 vices where prior authorization is performed by an entity under contract25 with the health insurance issuer.26 (2) A health insurance issuer shall make any current prior authoriza-27 tion requirements and restrictions, including the written clinical review28 criteria, readily accessible and conspicuously posted on its website or29 online portal to enrollees, health care professionals, and health care30 providers. Content published by a third party and licensed for use by a31 health insurance issuer may be made available through the health insurance32 issuer's secure, password-protected website or online portal as long as the33 access requirements of the website do not unreasonably restrict access.34 Requirements shall be described in detail, written in easily understandable35 language, and readily available to the health care professional and health36 care provider at the point of care. The website or online portal shall indi-37 cate for each service subject to prior authorization:38 (a) The date on which prior authorization became required for policies39 issued or health benefit plan documents delivered in Idaho, including40 the effective dates and the termination dates, if applicable, in Idaho;41 (b) The date on which the Idaho-specific requirement was listed on the42 website or online portal of the health insurance issuer;43 (c) If applicable, the date on which the prior authorization require-44 ment was removed for Idaho; and45 (d) If applicable, access to a standardized electronic prior autho-46 rization request transaction process.47 (3) The clinical review criteria must:48

5 (a) Be consistent with nationally accepted standards generally recog-1 nized by physicians and health care providers practicing in relevant2 medical and clinical specialties except where state law provides its3 own standard;4 (b) Be developed in accordance with the current standards of a national5 medical accreditation entity;6 (c) Ensure quality of care and access to needed health care services;7 (d) Be based on evidence from sources, including peer-reviewed scien-8 tific studies;9 (e) Be sufficiently flexible to allow deviations from norms when justi-10 fied on a case-by-case basis; and11 (f) Be evaluated and updated at least annually under the direction of a12 physician who:13 (i) Possesses a current, valid, and unrestricted license to prac-14 tice medicine in Idaho or in a state with substantially similar li-15 censing requirements; and16 (ii) Has knowledge of the standard of care in the community where17 care is proposed to be provided.18 (4) A health insurance issuer shall not deny a claim for failure to ob-19 tain prior authorization if the prior authorization requirement was not in20 effect on the date of service or if the claim or prior authorization require-21 ments were not publicly disclosed by the plan on the health insurance is-22 suer's website, online portal, or other materials.23 (5) If a health insurance issuer intends either to implement a new prior24 authorization requirement or restriction or to amend an existing require-25 ment or restriction, the health insurance issuer shall provide impacted26 enrollees, contracted health care professionals, and contracted health care27 providers of enrollees written notice of the new or amended requirement no28 less than sixty (60) days before the requirement or restriction is imple-29 mented. Written notice may take the form of a conspicuous notice posted30 on the health insurance issuer's public website or online portal for con-31 tracted health care professionals and contracted health care providers or32 email notice to health care professionals or health care providers. A health33 insurance issuer shall provide email notices to all impacted enrollees and34 to health care professionals or health care providers if the health care35 professional or health care provider has requested to receive the notice36 through email. A new or amended requirement shall not be implemented unless37 the health insurance issuer's website or online portal has been updated to38 reflect the new or amended requirement or restriction. Written notice of a39 new, amended, or restricted prior authorization requirement may be provided40 less than sixty (60) days in advance of implementation if a health insurance41 issuer determines and contemporaneously notifies the department in writing42 that:43 (a) The health insurance issuer has identified fraudulent or abusive44 practices related to the health care service;45 (b) The health care service is unavailable or scarce, necessitating the46 use of an alternative health care service;47 (c) The health care service is newly introduced to the health care mar-48 ket and a delay in providing coverage for the health care service would49 not be in the best interests of enrollees;50

6 (d) The health care service is the subject of a clinical trial autho-1 rized by the United States food and drug administration;2 (e) Changes to the health care service or its availability are other-3 wise required by law to be made by the health insurance issuer in less4 than sixty (60) days; or5 (f) The prior authorization requirement is being removed.6 (6) Health insurance issuers using prior authorization shall make sta-7 tistics available regarding prior authorization approvals and denials on8 their website or online portal in a readily accessible format. The reporting9 requirements of this subsection shall be implemented in a manner consistent10 with the public reporting requirements established under the centers for11 medicare and medicaid services (CMS) interoperability and prior authoriza-12 tion final rule (CMS-0057-F), as amended, to the extent applicable.13 (7) The implementation requirements of this section shall commence by14 January 1, 2027. Health insurance issuers may comply with the implementa-15 tion requirements of this section in phases, consistent with applicable fed-16 eral interoperability timelines.17 41-3506. PRIOR AUTHORIZATION APPLICATION PROGRAMMING INTERFACE. (1)18 If a health insurance issuer requires prior authorization of a health care19 service, the issuer or its contracted utilization review organization20 shall, to the extent required under applicable federal interoperability21 requirements, and by January 1, 2027, implement and maintain a prior autho-22 rization application programming interface (API).23 (2) The API shall:24 (a) Conform to the applicable interoperability standards adopted by25 the centers for medicare and medicaid services (CMS) in the CMS inter-26 operability and prior authorization final rule (CMS-0057-F), including27 health level 7 fast healthcare interoperability resources release28 4.0.1 or a successor version adopted by CMS;29 (b) Be capable of identifying, for items and services excluding pre-30 scription drugs unless otherwise required by federal law, whether prior31 authorization is required;32 (c) Identify payer-specific documentation requirements for each item33 or service that requires prior authorization;34 (d) Support the electronic creation and exchange of prior authoriza-35 tion requests and responses between health care professionals, health36 care providers, and the health insurance issuer; and37 (e) Be implemented in a manner that does not disrupt compliance with38 federal interoperability requirements.39 (3) A health insurance issuer may use an updated version of a required40 interoperability standard if such use is consistent with federal law and41 does not disrupt an end user's ability to access required data.42 (4) Nothing in this section shall require the creation of an Idaho-spe-43 cific electronic prior authorization.44 (5) For the purposes of this chapter, a prior authorization request45 shall be deemed received only upon submission of a complete prior authoriza-46 tion request.47 (a) A request shall be considered complete when the health insurance48 issuer has received all documentation and information reasonably nec-49

7 essary to make a determination under the terms of the health benefit1 plan.2 (b) A prior authorization request shall not fail to meet the definition3 of a complete prior authorization request due to minor clerical or tech-4 nical errors that do not materially affect the ability of the health in-5 surance issuer to make a determination.6 (c) A prior authorization request shall be presumed complete unless the7 health insurance issuer provides written notice within one (1) business8 day of receipt specifying with particularity any additional informa-9 tion reasonably necessary to adjudicate the request.10 41-3507. STANDARD PRIOR AUTHORIZATIONS. (1) If a health insurance11 issuer requires prior authorization of a health care service, the health12 insurance issuer shall render a decision and notify the enrollee and the en-13 rollee's health care professional or health care provider as expeditiously14 as the enrollee's condition requires but no later than seven (7) calen-15 dar days after receipt of a complete prior authorization request, unless a16 longer time frame is required under applicable federal law. Requests for17 additional information must be reasonably necessary to adjudicate the prior18 authorization request. As used in this section, "additional information"19 may include the results of any face-to-face clinical evaluation, a second20 opinion, or any other clinical information that is directly applicable to21 the requested service as may be required.22 (2) If a health insurance issuer determines that a prior authorization23 request is incomplete, the health insurance issuer shall notify the health24 care professional or health care provider within one (1) business day and25 shall specify in writing the information reasonably necessary to complete26 the request. The health insurance issuer may request additional information27 only once per prior authorization request unless the health care provider28 submits materially new clinical information.29 41-3508. EXPEDITED PRIOR AUTHORIZATIONS. (1) If requested by a treat-30 ing health care professional or health care provider for an enrollee, a31 health insurance issuer shall render a decision concerning urgent health32 care services as expeditiously as the enrollee's condition requires, but33 no later than seventy-two (72) hours after receipt of a complete expedited34 prior authorization request, unless a longer time frame is required pursuant35 to applicable federal law.36 (2) To facilitate the rendering of a prior authorization determina-37 tion pursuant to this section, a health insurance issuer shall establish a38 mechanism to ensure health care professionals have access to appropriately39 trained and licensed physicians preferably but not necessarily of the same40 specialty for consultation, designated by the health insurance issuer to41 make such determinations for prior authorization concerning urgent care42 services.43 41-3509. NOTIFICATIONS FOR ADVERSE DETERMINATIONS. If a health in-44 surance issuer makes an adverse determination, the health insurance issuer45 shall include the following in the notification to the enrollee and the en-46 rollee's health care professional or health care provider:47

8 (1) The reasons for the adverse determination and related evi-1 dence-based criteria, including a description of any missing or insuffi-2 cient documentation;3 (2) The right to appeal the adverse determination;4 (3) Instructions on how to file the appeal;5 (4) Additional documentation necessary to support the appeal; and6 (5) The right to request an independent external review pursuant to the7 provisions of chapter 59, title 41, Idaho Code.8 41-3510. PERSONNEL QUALIFIED TO REVIEW APPEALS. A health insurance9 issuer shall ensure that all appeals are peer reviewed by an appropriate10 licensed health care professional in the same or substantially similar field11 or specialty. The reviewing health care professional shall:12 (1) Possess a current and valid nonrestricted license to practice13 medicine with substantially similar licensing requirements to this state;14 (2) Be certified by the American board of medical specialties or the15 American osteopathic association within the relevant specialty of a physi-16 cian who typically manages the medical condition or disease;17 (3) Have training, knowledge, or experience of providing the health18 care services under appeal;19 (4) Not have been directly involved in making the adverse determina-20 tion; and21 (5) Consider all known clinical aspects of the health care service un-22 der review, including a review of all pertinent medical records provided to23 the health insurance issuer or health care provider, the health plan's clin-24 ical guidelines, and peer-reviewed scientific studies.25 41-3511. INSURER REVIEW OF PRIOR AUTHORIZATION REQUIREMENTS. A health26 insurance issuer shall periodically review its prior authorization require-27 ments and consider removal of prior authorization requirements.28 41-3512. REVOCATION OF PRIOR AUTHORIZATIONS. (1) A health insurance29 issuer may not revoke or further limit, condition, or restrict a previously30 issued prior authorization approval while it remains valid in accordance31 with this chapter unless:32 (a) The health insurance issuer has identified fraudulent or abusive33 practices related to the health care service;34 (b) The health care service is unavailable, necessitating the use of an35 alternative health care service;36 (c) The health care service is the subject of a new safety alert from the37 United States food and drug administration or is in response to a public38 health emergency;39 (d) The change is based on nationally recognized generally accepted40 standards developed in accordance with current standards of a national41 medical accreditation entity or specialty society;42 (e) Changes to the health care service or its availability are other-43 wise required by law to be made by the health insurance issuer within44 sixty (60) days; or45 (f) There is a material change in clinical circumstances that is sup-46 ported by documented medical evidence.47

9 (2) Notwithstanding any other provision of law, if a claim is properly1 coded and timely submitted to a health insurance issuer, the health insur-2 ance issuer shall make payment according to the terms of coverage on claims3 for health care services for which prior authorization was required and ap-4 proval received before the provision of health care services unless:5 (a) It is determined that the enrollee's health care professional or6 health care provider knowingly and without exercising prudent clinical7 judgment provided health care services that required prior authoriza-8 tion from the health insurance issuer or its contracted utilization re-9 view organization without first obtaining prior authorization for such10 health care services;11 (b) It is timely determined that the health care services claimed were12 not performed;13 (c) It is timely determined that the health care services provided by14 the enrollee's health care professional or health care provider were15 contrary to the instructions of the health insurance issuer or its con-16 tracted utilization review organization if contact was made between17 such parties before the health care services being provided;18 (d) It is timely determined that the person receiving such health care19 services was not an enrollee of the health care plan; or20 (e) The approval was based on a material misrepresentation by the en-21 rollee, health care professional, or health care provider. As used in22 this paragraph, "material" means a fact or situation that would have re-23 sulted in a substantial change in the determination had it been accu-24 rately disclosed in the submission.25 (3) Nothing in this section shall preclude a health insurance issuer or26 a utilization review organization from performing post-service reviews of27 health care claims for purposes of payment integrity or for the prevention of28 fraud, waste, or abuse.29 41-3513. LENGTH OF APPROVALS. (1) A prior authorization approval30 shall be valid for six (6) months after the date the health care profes-31 sional or health care provider receives the prior authorization approval.32 Provided, however, a health insurance issuer and an enrollee or enrollee's33 health care professional may extend a prior authorization approval for a34 longer period, by agreement.35 (2) Nothing in this section shall require a policy or plan to cover any36 care, treatment, or services for any health condition that the terms of cov-37 erage otherwise completely exclude from the policy's or plan's covered ben-38 efits without regard for whether the care, treatment, or services are medi-39 cally necessary.40 41-3514. APPROVALS FOR CHRONIC CONDITIONS. (1) If a health insurance41 issuer requires a prior authorization for a recurring health care service42 for the treatment of a chronic or long-term condition, the approval shall re-43 main valid for the lesser of twelve (12) months from the date the health care44 professional or health care provider receives the authorization approval or45 the length of the treatment as determined by the patient's health care pro-46 fessional. Provided, however, a health insurance issuer and an enrollee or47

10 the enrollee's health care professional may extend a prior authorization ap-1 proval for a longer period, by agreement.2 (2) Nothing in this section shall require a policy or plan to cover any3 care, treatment, or services for any health condition that the terms of cov-4 erage otherwise completely exclude from the policy's or plan's covered ben-5 efits without regard for whether the care, treatment, or services are medi-6 cally necessary.7 41-3515. CONTINUITY OF PRIOR APPROVALS. (1) Upon receipt of informa-8 tion documenting a prior authorization approval from the enrollee or from9 the enrollee's health care professional or health care provider, a health10 insurance issuer shall honor a prior authorization granted to an enrollee11 from a previous health insurance issuer for at least the initial ninety (90)12 days of an enrollee's coverage under a new health plan, subject to the terms13 of the enrollee's coverage agreement.14 (2) During the time period described in subsection (1) of this section,15 a health insurance issuer may perform its own review to grant a prior autho-16 rization approval, subject to the terms of the enrollee's coverage agree-17 ment.18 (3) Nothing in this chapter shall require a policy or plan to cover any19 care, treatment, or services for any health condition that the terms of cov-20 erage otherwise completely exclude from the policy's or plan's covered ben-21 efits without regard for whether the care, treatment, or services are medi-22 cally necessary.23 (4) Nothing in this chapter shall prevent a health insurance issuer to24 engage an enrollee with an option to consider clinically appropriate alter-25 natives.26 41-3516. ENFORCEMENT AND ADMINISTRATION. (1) In addition to the en-27 forcement powers granted to it by law to enforce the provisions of this chap-28 ter, the department is granted specific authority to issue a cease-and-de-29 sist order or require a health insurance issuer or utilization review organ-30 ization, or both, to submit a plan of correction for violations of this chap-31 ter. Subject to rules promulgated by the department pursuant to chapter 52,32 title 67, Idaho Code, and after proper notice and the opportunity for a hear-33 ing, the department may impose on a health insurance issuer, health benefit34 plan, or utilization review organization an administrative fine not to ex-35 ceed ten thousand dollars ($10,000) per violation for failure to submit a re-36 quested plan of correction, failure to comply with its plan of correction,37 or repeated violations of this chapter. All fines collected by the depart-38 ment pursuant to this section shall be deposited in the state general fund.39 The department may also exercise all authority granted to it under the pro-40 visions of chapter 59, title 41, Idaho Code, to deny or revoke approval of a41 utilization review organization for a violation of this chapter.42 (2) An enrollee or an enrollee's health care provider who has evidence43 that the enrollee's health insurance issuer or health benefit plan is in44 violation of the provisions of this chapter may file a complaint with the45 department. The department shall review all complaints received and in-46 vestigate all complaints that it deems to state a potential violation. The47 department shall fairly, efficiently, and timely review and investigate48

11 complaints and shall provide the subject of the complaint an opportunity to1 refute the evidence against it. Health insurance issuers, health benefit2 plans, and utilization review organizations found to be in violation of this3 chapter shall be penalized in accordance with this section.4 (3) There shall be no private right of action under this chapter.5 41-3517. REPORTS TO THE DEPARTMENT. (1) By June 1, 2027, and each June6 1 thereafter, a health insurance issuer shall report to the department, on a7 form issued by the department, the following aggregated trend data, de-iden-8 tified of protected health information, related to the insurer's practices9 and experience for the prior plan year for health care services submitted for10 payment:11 (a) The number of prior authorization requests;12 (b) The percentage of prior authorization requests denied;13 (c) The percentage of prior authorization appeals received;14 (d) The percentage of adverse determinations reversed on appeal;15 (e) The percentage of prior authorization requests that were not sub-16 mitted electronically;17 (f) As a percentage by service, the ten (10) health care services that18 were most frequently denied through prior authorization; and19 (g) The five (5) reasons prior authorization requests were most fre-20 quently denied.21 (2) All reports required by this section shall be considered public22 records pursuant to chapter 1, title 74, Idaho Code, and the department shall23 make all reports freely available to requesters and post all reports to its24 public website without redactions.25 41-3518. FALSE REQUESTS FOR PRIOR AUTHORIZATION. If a health insur-26 ance issuer has clear and convincing evidence that a health care profes-27 sional or health care provider has knowingly and willfully submitted false28 or fraudulent requests for prior authorization to the health insurance is-29 suer, the health insurance issuer shall notify and provide that information30 to the department director. After receipt of such notification and infor-31 mation, the director shall forward these reports to the board of medicine or32 such other licensing agency with oversight of the health care professional33 or health care provider and to the office of the prosecuting authority having34 jurisdiction.35 41-3519. DE MINIMIS PRIOR AUTHORIZATION UTILIZATION EXEMPTION. (1) A36 health insurance issuer that, for the prior plan year, required prior autho-37 rization for less than one percent (1%) of claims submitted for payment under38 health benefit plans issued or delivered in Idaho may elect to be exempt from39 the requirements of this chapter.40 (2) The election shall be made by filing an annual attestation with the41 department, in a form and manner specified by the department, demonstrating42 that the health insurance issuer meets the threshold provided for in subsec-43 tion (1) of this section.44 (3) Upon request, the health insurance issuer shall provide records45 reasonably necessary for the department to verify the attestation provided46 for in subsection (2) of this section. If the department determines the47

12 health insurance issuer does not meet the threshold, the department may re-1 voke the exemption and require compliance within a reasonable period.2 41-3520. RULES. The department shall have the authority to promulgate3 rules, subject to legislative approval, pursuant to the provisions of chap-4 ter 52, title 67, Idaho Code, to govern the administration of this chapter.5

SECTION 2. This act shall be in full force and effect on and after Jan-6 uary 1, 2027.7