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News & Advocacy

State Update: Prior Authorization Law Now in Effect

posted: January 1, 2017

The Ohio State Medical Association (OSMA) has provided a guide for implementation of the new prior authorization law in Ohio. Provisions in the legislation partly take effect in 2017 with the rest of the bill becoming fully implemented in January 2018.

January 2017 Provisions Include:

  • Insurers must disclose all PA rules to participating providers, including specific information or documentation that a provider must submit in order for the PA request to be considered complete.
  • Insurers must disclose to all participating providers all new prior authorization requirements at least 30 days prior to the effective date of the new requirement.
  • Enrollees of the health plan must receive basic information about which drugs and services will require prior authorization.
  • A provision prohibiting retroactive denials when, on the date the provider renders the prior approved service: The patient is eligible; the patient’s condition hasn’t changed; the provider submits an accurate claim that matches the information submitted by the provider in the approved PA request.
  • A provision allowing a retrospective review of a claim where a PA was required but not obtained when the service in question meets all of the following: The service is related to another service for which a PA has already been obtained and has already been performed; The service was not known to be needed at the time the original prior authorized service was performed; The need for the new service was revealed at the time the original authorized service was performed.
  • Insurers must allow for a 12-month PA for medications to treat a chronic disease under certain circumstances.