This chart highlights the state laws related to prior authorizations. Check back often, as this chart is updated frequently.
If you have a self-funded plan, certain state laws may not apply. For information on how to determine if your plan is self-funded, see our blog post.
For more health insurance information, visit our Health Insurance Materials & Resources.
| State | State Law Consumer Protection on Prior Authorizations | Brief Description of the State Law Protection | Additional State Laws about Prior Authorization | |||||
|---|---|---|---|---|---|---|---|---|
| ALABAMA | Alabama Code. Title 27 - Insurance, Chapter 3A - Health Care Service Utilization Review, § 27-3A-1 to 27-3A-6) | https://alison.legislature.state.al.us/code-of-alabama?utm_sq=g9tn2rrfob | Determination required within two business days of receipt of request and documentation; appeal determinations must be issued by a physician in the same or similar specialty within thirty days; expediated appeal over the telephone by patient's attending physician available for future or ongoing authorization requests; insurer must allow twenty-four hours for authorization requests after emergency admissions or procedures. | |||||
| ALASKA | Alaska Statutes § 21.07.020 – Required Contract Provisions for Health Care Insurance Policy | https://www.akleg.gov/basis/statutes.asp#21.07.020 | Prohibits retroactive denial of preauthorization unless preauthorization is based on materially incomplete or inaccurate information. | |||||
| ARIZONA | Arizona Revised Statutes: § 20-3403 – Prior Authorization Requirements; § 20-3404 – Prior Authorization Requirement Timelines; § 20-3405 – Prior Authorization of Prescription Drugs for Chronic Pain Conditions; § 20-2534 – Expedited Medical Review | https://www.azleg.gov/arsDetail/?title=20 | Requires availability of universal electronic prior authorization request forms; determination required within five days for urgent requests and fourteen days for all other requests; prohibits retroactive denial of preauthorization unless there was fraud or misrepresentation; prior authorization for prescription drugs for chronic pain must last at least six months. | |||||
| ARKANSAS | Arkansas Code Title 23 - Public Utilities and Regulated Industries, Subtitle 3 - Insurance, Chapter 99 - Healthcare Providers, Subchapter 11 - Prior Authorization Transparency Act, §§ 23-99-1101 to -1119) | https://advance.lexis.com/container?config=00JAA3ZTU0NTIzYy0zZDEyLTRhYmQtYmRmMS1iMWIxNDgxYWMxZTQKAFBvZENhdGFsb2cubRW4ifTiwi5vLw6cI1uX&crid=50a2e0de-020b-42cc-9146-7bdd0258bf87&prid=bd49dca9-ebef-438a-a9f2-f7d1cadb9001 | Determination required within two business days of receipt for nonurgent prior authorization requests and one business day for urgent requests; determination required within seventy-two hours for prescription drug requests; prohibits denials of prior authorization for certain prescription pain medications if patient has a terminal illness; prohibits withdrawl of authorization for lack of medical necessity unless notification is provided three business days before the scheduled service; prior authorization must remain valid for at least ninety days. | Act 389 (2025) Amends Arkansas Code Title 23, Chapter 99 to create Subchapter 19 - Prohibition on Prior Authorizations for Treatment Health Crisis (Arkansas Code §§ 23-99-1901 to 1903) | https://www.arkleg.state.ar.us/Home/FTPDocument?path=%2FACTS%2F2025R%2FPublic%2FACT389.pdf | |||
| CALIFORNIA | California Law, Health and Safety Code – Division 2. Licensing Provisions – Chapter 2.2 Health Care Service Plans, Article 5. Standards - §§ 1367.206, 1367.241 | https://leginfo.legislature.ca.gov/faces/codes_displayText.xhtml?lawCode=HSC&division=2.&title=&part=&chapter=2.2.&article=5. | Allows providers or enrollees to appeal denials of prior authorization requests for prescription drugs. Insurers must review and decide requests for prior authorization for prescription drugs within 72 hours for nonurgent cases and within 24 hours in exigent circumstances. | California Law, Health and Safety Code – Division 2. Licensing Provisions – Chapter 2.2 Health Care Service Plans, Article 5. Standards - §§ 1367.206, 1367.241 (insurer cannot require prior authorization for biomarker testing for patients with advanced or metastatic stage 3 or 4 cancer) | https://leginfo.legislature.ca.gov/faces/codes_displayText.xhtml?lawCode=HSC&division=2.&title=&part=&chapter=2.2.&article=5. | |||
| COLORADO | Colorado Revised Statutes: § 10-16-112.5 – Prior Authorization, § 10-16-113 – Procedures for Denial of Benefits, § 10-16-113.5 – Independent External Review, § 10-16-124.5 – Prior Authorization Drug Benefits | https://advance.lexis.com/documentpage/?pdmfid=1000516&crid=8df6e399-a9a3-478e-a62d-3639e23fcbcc&nodeid=AAKAARAABAAB&nodepath=%2FROOT%2FAAK%2FAAKAAR%2FAAKAARAAB%2FAAKAARAABAAB&level=4&haschildren=&populated=false&title=Article+16+Health+Care+Coverage&config=014FJAAyNGJkY2Y4Zi1mNjgyLTRkN2YtYmE4OS03NTYzNzYzOTg0OGEKAFBvZENhdGFsb2d592qv2Kywlf8caKqYROP5&pddocfullpath=%2Fshared%2Fdocument%2Fstatutes-legislation%2Furn%3AcontentItem%3A61P5-WPR1-DYDC-J54G-00008-00&ecomp=_g1_9kk&prid=927d3974-436d-4c64-a0e2-00c24efd6732 | Insurer must make prior authorization requirements and restrictions, including written clinical criteria, accessible on website; requires determination for medical service requests within 5 business days for nonurgent requests, within 2 business days for urgent requests; requires prior authorizations to remain valid for at least 1 year; prohibits prior authorization requirements more than once evert 3 years for chronic maintenance drugs; prohibits retroactive denials of prior authorization except for fraud or misrepresentation; requires 2 levels of internal review with involvement of physician and clinical peer along with option to seek independent external review; requires insurer to allow patient to be present at second level internal review; requires determination for prescription requests within 3 business days for nonurgent requests and 1 business day for urgent requests. | Colorado Revised Statutes, Title 25.5 - Health Care Policy and Financing, Article 5 - Colorado Medical Assistance Act, Part 4 - Statewide Managed Care System,§ 25.5-406.1 (1)(j)(II) (prohibits prepaid inpatient health plans from requiring prior authorization for outpatient psychotherapy) | https://advance.lexis.com/documentpage/?pdmfid=1000516&crid=7cb2effd-efde-4ca7-a1da-0a8dcf641091&nodeid=ABAAAFAACAAFAAH&nodepath=%2FROOT%2FABA%2FABAAAF%2FABAAAFAAC%2FABAAAFAACAAF%2FABAAAFAACAAFAAH&level=5&haschildren=&populated=false&title=25.5-5-406.1.+Required+features+of+statewide+managed+care+system.&config=014FJAAyNGJkY2Y4Zi1mNjgyLTRkN2YtYmE4OS03NTYzNzYzOTg0OGEKAFBvZENhdGFsb2d592qv2Kywlf8caKqYROP5&pddocfullpath=%2Fshared%2Fdocument%2Fstatutes-legislation%2Furn%3AcontentItem%3A630C-J533-CH1B-T0SN-00008-00&ecomp=6gf59kk&prid=c08be0a1-dfa7-4eaf-8c6f-96c161787947 | |||
| CONNECTICUT | Connecticut General Statutes, Title 38a, Chapter 700c - Health Insurance, § 38a-472g – Restrictions Applicable to Prior Authorization, § 38a-492l – Mandatory Coverage for Neuropsychological Testing for Children Diagnosed with Cancer, § 38a-514g – Acute Inpatient Psychiatric Coverage, §38a-525a – Prior Authorization Prohibited for Certain 911 Calls; §38a-544b - Prior Authorization for Naloxone, § 38-591l – Independent Review | https://www.cga.ct.gov/current/pub/title_38a.htm | Prohibits recission of prior authorization unless notice is provided at least three business days before the scheduled treatment; prohibits insurers from requiring prior authorization for neuropsychological testing to assess the extent of any cognitive delays in children diagnosed with cancer; prior authorization not required for acute inpatient psychiatric services; prohibits prior authorization for certain 911 emergency calls or transportation to hospital by ambulance when medically necessary; prior authorization for naloxone hydrochloride or similar drugs not required; provides for external review of final prior authorization denials by independent review organizations. | |||||
| DELAWARE | 2016 House Bill 381 (Codified at Delaware Code Title 18, Chapter 33, Subchapter II – Pre-Authorization Transparency §§ 3371–3381) | https://delcode.delaware.gov/title18/c033/sc02/index.html | Requires insurers to make pre-authorization requirements, restrictions, and clinical criteria accessible on their website; requires determination within two business days for nonurgent pharmaceuticals and eight business days for nonurgent health-care services; prohibits retroactive denial of preauthorization based on medical necessity (when a prudent physician would provide the service to the patient in accordance with the generally accepted standards of practice, consistent with the treatment of the conditions, not for convenience); requires preauthorization to be valid for at least 1 year for pharmaceuticals and 7 months for health-care services; bundled services are co-approved if 1 service obtains pre-authorization. | |||||
| *DISTRICT OF COLUMBIA | Code of the District of Columbia, Title 31 - Insurance and Securities, Subtitle IV - Health and Related Insurance, Chapter 38F - Prior Authorization by a Utilization Review Entity, §31-3875.02 - Prior authorization requirements and Restrictions; §31-3875.03 - Prior authorization in non-urgent, urgent, and emergency circumstances | https://code.dccouncil.gov/us/dc/council/code/titles/31/chapters/38F | Prior authorization policies to be easily understandable, contain clinical criteria and drug formularies, and be available online, via email or written request or by phone; prior authoriziations permitted only for medically necessary alternative care or services considered to be experimental or investigational; prior authorization determinations may not be based solely on cost; prior authorization prohibited for medication-assisted treatment and pre-hospital stabilization and transport; prior authorization requests must be decided within 24 hours if urgent, and for non-urgent requests - 3 business days if submitted electronically and 5 days if submitted by mail, phone, or fax; adverse prior authorization decisions must explain reason for denial and include appeal information; emergency providers must notify insurer of emergency admission or service within 24 hours; emergency care presumed to be medically necessary if a provider certifies it as such within 72 hours; prior authorizations are presumed valid for at least a year even if dosage changes or for duration of medically necessary chronic treatment; and prior authorization cannot be revoked or restricted if care provided within 45 business days of approval. | |||||
| FLORIDA | Florida Statutes § 627.42392 – Prior Authorization, § 627.4239 – Coverage of Cancer Treatment Drugs | http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&URL=0600-0699/0627/0627PartIIContentsIndex.html&StatuteYear=2021&Title=%2D%3E2021%2D%3EChapter%20627%2D%3EPart%20II | Requires use of standardized approved prior authorization form that contains all clinical documentation necessary for insurer to make decision; prohibits insurers from denying coverage for any cancer drug on the grounds that it is not approved by FDA for a particular indication when such drug is recognized for treatment in a standard reference compendium or recommended in medical literature. | |||||
| GEORGIA | Ensuring Transparency in Prior Authorization Act (2021) (Codified at Georgia Code §§ 33-46-20 to -32) | http://www.lexisnexis.com/hottopics/gacode/default.asp | Requires insurers to make prior authorization requirements and restrictions, including written clinical criteria in readily understandable language, readily accessible on their website; requires insurers to make all adverse decisions by a physician who is in the same specialty that typically treats the patient's condition and who has experience with the patient's condition; limits insurers from revoking or restricting prior authorization if health care services are performed within forty-five business days of approval; prohibits insurers from requiring prior authorization for emergency/urgent health care services or covered health care services incidental to the primary covered health care service; requires determination within seventy-two hours for urgent health care services. | |||||
| HAWAII | ||||||||
| IDAHO | Idaho Code, Title 41 - Insurance: Chapter 39 - Managed Care Report, § 41-3930 – Utilization Management Program Requirements; Chapter 18 - The Insurance Contract, § 41-1846 – Health Care Policies Requirements; Chapter 59 - Idaho Health Carrier External Review Act, §§ 41-5901 to –5917 | https://legislature.idaho.gov/statutesrules/idstat/title41/ | Prior authorization requirements must be disclosed on insurer websites or annally to policyholders; prohibits insurers from requiring prior authorization for emergency services; managed care organizations must decide non-urgent requests within 2 business days; prohibits insurers from rescinding prior authorization after service is provided except for fraud, misrepresentation, or non-payment of premium; requires insurers to submit to external review for denial of prior authorization or coverage after exhaustion of internal appeals. | |||||
| ILLINOIS | Prior Authorization Reform Act (2021) (Codified at 215 ILCS 200), Health Carrier External Review Act (2010) (Codified at 215 ILCS 180), | https://www.ilga.gov/legislation/ilcs/ilcs3.asp?ActID=4201&ChapterID=22 | Requires insurers to make prior authorization requirements, restrictions, and clinical criteria readily accessible on their website; requires determination within 5 calendar days for nonurgent requests and 48 hours for urgent requests; requires prior authorization to remain valid for the lesser of at least 6 months or the length of the treatment; requires prior authorization to remain valid for the lesser of at least twelve months or the length of the treatment for the treatment of chronic or long-term conditions; requires insurers to submit to external review for denial of prior authorization or coverage. | Managed Care Reform and Patients Rights Act (2000) (Codified at 215 ILCS 134) (requires prior authorizations for prescription drugs be determined withing 72 hours or within 24 hours if expedited; prohibits prior authorization for emergency services or post-stablization medical services) | https://www.ilga.gov/Legislation/ILCS/Articles?ActID=1265&ChapterID=22 | |||
| INDIANA | Indiana Code Title 27 - Insurance, Article 1 - Department of Insurance, Chapter 37.5 Health Care Service Prior Authorization | https://law.justia.com/codes/indiana/title-27/article-1/chapter-37-5/ | Requires insurers to make the specific information required for prior authorization along with CPT codes for which prior authorization is required for available on their website; requires determination within 72 hours for urgent requests and within 7 days for nonurgent requests; prohibits insurers from retroactively denying prior authorization except for fraud or misrepresentation of material information; prohibits prior authorization for first 12 physical therapy or chiropractic visits; prohibits denials on the sole basis that referring provider is out of network. | 2022 House Bill 1271 | http://iga.in.gov/legislative/2022/bills/house/1271#document-a343b734 | Proposing to require insurers to allow a clinical peer to peer conversation between the patient's provider and insurer's provider after denial of prior authorization requests, waiver of prior authorization requirements for providers that meet criteria, providing for independent external review | ||
| IOWA | Iowa Code Title XIII - COMMERCE Chapter 514F - UTILIZATION AND COST CONTROL Section 514F.8 - Prior authorizations — reimbursement; Chapter 514C - SPECIAL HEALTH AND ACCIDENT INSURANCE COVERAGES Section 514C.16 - Emergency room services | https://www.legis.iowa.gov/law/iowaCode/chapters?title=XIII | Requires reimbursement provided per a prior authorization so long as certain conditions are met; prior authorization shall remain valid for up to 90 days; prior authorizations must be determined within 48 hours after receipt for urgent requests, within 10 calendar days for nonurgent requests, but up to 15 calendar days may be allowed if a nonurgent request for prior authorization is complex or unique or there is an unusually high volume for requests; prohibits prior authorization for emergency services. | 2024 Iowa Code Title XIII - COMMERCE Chapter 505 - INSURANCE DIVISION Section 505.26 - Prior authorization for prescription drug benefits — standard process and form — response requirements (requires insurers and pharmacy benefits managers to provide on their websites a list of drugs that require prior authorization along with a clear process to request it, including any clinical criteria; requires insurer to decide prior authorization request within 5 business days for nonurgent requests and within 72 hours for urgent requests. ) | https://www.legis.iowa.gov/docs/code/2025/505.26.pdf | |||
| KANSAS | Kansas Statutes, Article 32- Health Maintenance Organizations and Medicare Provider Organizations, § 40-3229 – Prior Authorization Requirements for Emergency Medical Treatments | https://www.kslegislature.gov/li/b2025_26/statute/040_000_0000_chapter/040_032_0000_article/040_032_0029_section/040_032_0029_k/ | Prohibits health maintenance organizations from denying emergency medical services based on a lack of prior authorization; requires enrollee to notify HMO within 24 hours or as soon as reasonable possible. | Kansas Statutes, Article 46 - Managed Care, §40-4603 - Same; emergency services, prohibitions on health care plan; prior authorizations after condition stabilized; post evaluation or post stabilization services (prohibits health benefits plans from denying emergency medical services based on lack of prior authorization; prohibits rescission or modification of prior authorization for services rendered; allows plans to require prior authorization for continuing and other treatment after emergency stabilization) | https://www.kslegislature.gov/li_2022/b2021_22/statute/040_000_0000_chapter/040_046_0000_article/040_046_0003_section/040_046_0003_k/ | |||
| KENTUCKY | Kentucky Revised Statutes Title XXV. Business and Financial Institutions § 304.17A-603.Application of KRS 304.17A-600 to 304.17A-633; written procedures for coverage and utilization review determinations to be accessible on insurers' Web sites; preauthorization review requirements for insurers; § 304.17A-167 - Process and standards for electronic prior authorizations - Prior authorizations of drugs for ongoing medication therapy - Requirements - Time span of authorization - Exemptions | https://apps.legislature.ky.gov/law/statutes/chapter.aspx?id=38715 | Requires insurers to make prior authorization requirements (including a list of services and codes and the procedure used to make determinations) available on their website; requires determination within twenty-four hours for urgent requests and within five days for nonurgent requests; prior authorizations for most prescription drugs for maintenance conditions will be valid for 1 year even if dosage changes. | |||||
| LOUISIANA | 2024 Louisiana Laws Revised Statutes Title 22 - Insurance §22:1260.47. Prior authorization; denial of claims | https://www.legis.la.gov/legis/Law.aspx?d=1337079#:~:text=(1)%20Benefit%20limitations%2C%20such,provider%20prior%20to%20healthcare%20services | Prohibits insurers from denying claims for services includes in a prior authorization unless certain circumstances are met; prior authorizations must be a valid for at least 3 months. | 2024 Louisiana Laws Revised Statutes Title 22 - Insurance §22:1060.13. Prior authorization; time periods (provides for expedited review process of prior authorization requests required to diagnose or treat cancer; requires insurer to respond as soon as possible but no later than 2 business days after receipt of request) | https://www.legis.la.gov/legis/Law.aspx?d=1337011#:~:text=For%20any%20services%20typically%20covered,the%20provider%20requesting%20prior%20authorization. | |||
| MAINE | Maine Revised Statutes, Title 24-A - Maine Insurance Code, Chapter 56-A - Health Plan Improvement Act, Subchapter 1: Health Plan Requirements; § 4304 – Utilization Review, §4312 – Independent External Review | https://legislature.maine.gov/statutes/24-A/title24-Asec4304.html | Requires insurers to make determinations within the lesser of 72 hours or 2 business days for nonemergency requests; prohibits revocation of prior authorization unless there was fraud or materially incorrect information was provided; ; insurer cannot deny a claim if a service cannot be provided on date indicated in prior authorization request if service provided within 14 days before or after the approved date; prohibits non-emergency coverage denials based only on a provider's failure to request prior authorization; prohibits prior authorization for emergency services and post-evaluation or post-stabilitization services provided durign same encounter; insurers must provide patients with a right to an independent external review of all adverse coverage decisions when the patient has exhausted the internal appeals process; authorized representatives may pursue an external review on behalf of a patient. | |||||
| MARYLAND | Maryland Statutes Health - General Title 19 - Health Care Facilities Subtitle 1 - Health Care Planning and Systems Regulation Part I - Maryland Health Care Commission Section 19-108.2 - Benchmarks for Preauthorization of Health Care Services | https://mgaleg.maryland.gov/mgawebsite/laws/statutes | Requires insurers to accept electronic requests for pharmaceuticals and provide real time determinations for certain common prescriptions, determinations within 1 business day for nonurgent drugs, and determinations within two business days for nonurgent services; requires insurers to provide key criteria for making determinations. | Maryland Statutes Insurance, Title 15 - Health Insurance Subtitle 8 - Required Health Insurance Benefits Section 15-854 - Prior Authorization for Prescription Drug (requires insurers to provide prior authorization for at least one year or the course of treatment for drugs used to treat chronic conditions) | https://mgaleg.maryland.gov/mgawebsite/Laws/StatuteText?article=gin§ion=15-854&enactments=false#:~:text=(b)%20(1)%20(,to%20treat%20a%20chronic%20condition. | |||
| MASSACHUSETTS | Massachusetts General Laws 176O Health Insurance Consumer Protections § 25 – Use and Acceptance of Specifically Designated Prior Authorization Forms | https://malegislature.gov/Laws/GeneralLaws/PartI/TitleXXII/Chapter176O/Section25 | Requires determination within two business days for requests. | 2021 Senate Bill 637 | https://malegislature.gov/Bills/192/S637 | Proposing to require insurers to publish their prior authorization requirements, limiting ability to retroactively deny prior authorization unless it was obtained because of materially inaccurate information | ||
| MICHIGAN | Michigan Compiled Laws, Patient's Rigth to Independent Review Act 251 of 2000, §§ 550.1901 to .1929 | https://www.legislature.mi.gov/Laws/MCL?objectName=mcl-550-1901 | Requires insurers to submit to independent external review of coverage determination; requires determination within fifteen business days for nonurgent prescription drug requests and within seventy-two hours for expedited prescription drug requests. | Michigan Compiled Laws, Chapter 400, The Social Welfare Act 280 of 1939, County Department of Social Services, §400.109h -Prior authorization for certain prescription drugs not required…(Michigan Medicaid cannot mandate prior authorization for certain categories of drugs—such as anticonvulsants, antidepressants, antipsychotics, HIV treatments, certain cancer drugs, and opioid withdrawal medications—as long as they align with standard medical reference) | https://www.legislature.mi.gov/Laws/MCL?objectName=MCL-400-109H#:~:text=400.109h%20Prior%20authorization%20for,with%20managed%20care%20organizations%3B%20definitions. | 2021 Senate Bill 0247 | http://www.legislature.mi.gov/(S(muaz4rps0a31kf0l1hktfqp2))/mileg.aspx?page=GetObject&objectName=2021-SB-0247 | Proposing reduced timeline for determinations of seven calendar days for nonurgent requests and seventy-two hours for urgent reuqest, requiring insurers to publish prior authorization criteria online, requiring insurers to permit clinical peer to peer review requets, minimum durations for prior authorization validity of at least sixty calendar days |
| MINNESOTA | Minnesota Statutes Chapter 62M Utilization Review of Health Care §§ 62m.01 to .19 | https://www.revisor.mn.gov/statutes/cite/62M | Requires determination within 5 business days for nonurgent requests and within forty-eight hours with a minimum of 1 business day for urgent requests; prohibits retroactive revocation or limitations on prior authorization except for fraud or misinformation; insurer must provide provider or patient with determination criteria upon request; requires appeals of adverse prior authorization requests to be reviewed by a clinical peer of the patient's requesting provider. Beginning January 2026, prior authorization is prohibited for the following so long as eligibilty criteria are met: non-medication outpatient mental health treatment and substance use disorder care, non-medication antineoplastic cancer treatments aligned with NCCN guidelines, preventive services rated A or B by the USPSTF, pediatric hospice care, neonatal abstinence programs; and prior authorization for chronic conditions will not expire unless the standard of care changes. | |||||
| MISSISSIPPI | Mississippi Code 1972 Title 83 - INSURANCE, Article 5 - GENERAL PROVISIONS RELATIVE TO INSURANCE AND INSURANCE COMPANIES (§§ 83-5-1 — 83-5-937); Article 15 - MISSISSIPPI PRIOR AUTHORIZATION REFORM ACT (§§ 83-5-901 — 83-5-937) | https://law.justia.com/codes/mississippi/title-83/article-5/article-15/ | Insurers must publicly maintain and post a complete list of services that require prior authorization along with clear clinical criteria; review criteria must follow nationally recognized, evidence-based standards and be updated at least annually; prohibits retroactive denials if the prior authorization wasn’t required on the date of service; services that are routinely used as part of authorized care are considered incidental and cannot be denied; insurers must provide at least 60 days' notice before adding or changing prior authorization requirements; non-urgent prior authorization requests must be decided within 7 calendar days, urgent requests must be decided in 48 hours; prior authorization is not required for emergency services. | Mississippi Code 1972 (2024) Title 83 - INSURANCE (§§ 83-1-1 — 83-87-9) Chapter 9 - ACCIDENT, HEALTH AND MEDICARE SUPPLEMENT INSURANCE (§§ 83-9-1 — 83-9-403) ACCIDENT AND HEALTH INSURANCE (§§ 83-9-1 — 83-9-36.2) Section 83-9-6.3 - Standardized prior authorization form for obtaining prior authorization for prescription drug benefits (requires determination within 2 business days of receipt for prescription drugs) | https://law.justia.com/codes/mississippi/title-83/chapter-9/accident-and-health-insurance/section-83-9-6-3/ | |||
| MISSOURI | Revised Statutes of Missouri §§ 376.1350, –.1389 Health Care Utilization Review | https://revisor.mo.gov/main/OneSection.aspx?section=376.1350&bid=47950 | Requires determination within two business days of request and within one working day for concurrent review requests; provides for independent external review of adverse coverage determinations after two levels of internal appeals. | |||||
| MONTANA | 2019 Montana House Bill 555 (Codified at Montana Code §§ 33-32-101, -102, -211, -212, -215, -221). | https://leg.mt.gov/bills/mca/title_0330/chapter_0320/parts_index.html | Requires determination within seven business days for nonurgent requests and within twenty-four hours for urgent requests; insurers must make clinical review criteria and standards for prior authorization available on their website; prior authorizations must remain valid for at least three months; no prior authorization may be required for generic drugs not listed as controlled substances when prescribed continuously for 6 months, drugs previously approved for therapeutic duplication, dosage adjustments, or long-acting anti-psychotics, generic oral or inhaled asthma/chronic lung disease medications, and insulin; denials of prior authorization requests must be made by a physician who specializes in treating the relevant condition; denials of prior authorization for prescription drugs must include a list of alternative formulary drugs; prior authorizations for chronic condition services must be valid for at least 6 months and those for drugs to treat chronic conditions must be valid for at least 12 months; prior authorizations for chronic condition services must remain valid for 3 months after changing plans. | |||||
| NEBRASKA | Nebraska Revised Statutes, Chapter 44, § 44-5437 to -5444 | https://nebraskalegislature.gov/laws/statutes.php?statute=44-5437&utm_source=chatgpt.com | Insurers must publicly post prior authorization requirements on their websites and notify providers at least 60 days before new or revised prior authorization rules take effect; adverse decisions cannot be based solely on artificial intelligence and must involve a physician and, if requested, a peer-to-peer clinician review is required; urgent request must be decided within 72 hours (shrinks to 48 hours in 2028) and nonurgent requests must be decided within 7 days; prior authorizations will generally remain valid for up to one year; prior authorizations will be granted for 60 days if a patient changes plans; prohibits prior authorization for emergency services, emergency ground transport, and preventative services. | Nebraska Revised Statutes, Chapter 68, §68-955 (for Medicaid recipients, prior authorization for treatment of chronic mental health conditions may be waived for patients who remain on the same antidepressant, antipsychotic, or anticonvulsant within the last 90 days, the preferred alternative failed or caused adverse reactions, and the provider certifies the prescribed drug as medically necessary) | https://nebraskalegislature.gov/laws/statutes.php?statute=68-955 | |||
| NEVADA | Nevada Revised Statutes 695G.150 Authorization of Recommended and Covered Health Care Services, § 695G.241 External Review of Adverse Determination. | https://www.leg.state.nv.us/NRS/NRS-695G.html | Requires insurers to establish and provide written criteria for prior authorization determinations; requires insurers to submit an an external review of adverse coverage decisions if the patient has exhausted all internal appeals. | |||||
| NEW HAMPSHIRE | New Hampshire Revised Statutes § 420-J-3 - Clinical Review Criteria; § 420-J:6 – Utilization Review, § 420-J:7-b – Prescription Drugs, § 420-J:5 Grievance Procedures, § 420-J:5-a Right to External Review. | https://www.gencourt.state.nh.us/rsa/html/NHTOC/NHTOC-XXXVII-420-J.htm | When requests for prior authorization are made electronically, decisions must be made within 72 hours for urgent requests and 7 days of nonurgent requests; non-electronic requests for prior authorization must be decided within 72 hours for urgent requests and within 14 days for nonurgent requests; requires determination within 48 hours for prescription drug requests; requires insurers to have a clinical peer review appeals of adverse coverage determinations; requires insurers to submit to an independent external review for adverse coverage determinations when the patient has exhausted the normal internal appeals process; prior authorizations cannot be revoked, limited, or restricted if care provided within 60 days of approval. | |||||
| NEW JERSEY | New Jersey Statutes N.J.S.A. 17B:30-55.1, et seq. | https://pub.njleg.state.nj.us/Bills/2022/PL23/296_.HTM#:~:text=The%20payer%20shall%20report%20annually,arbitration%20pursuant%20to%20this%20subsection. | Requires insurers to publish prior authorization requirements and restrictions, including written clinical criteria, on their website; requires determinations within 24 hours for urgent requests and within 72 hours for nonurgent requests; prior authorizations remain valid for 60 days after switching health plans; prior authorization denials must be made by a physician who specializes in the same field as the treating provider. | 2022 Bill A1255 - Ensuring Transparency in Prior Authorization Act, 2022 Bill S202 - New Jersey Respect for Physicians Act | https://www.njleg.state.nj.us/bill-search | Ensuring Transparency in Prior Authorization Act - requiring insurers to publish prior authorization requirements and restrictions, including written clinical criteria, on their website; requiring determinations within two business days for nonurgent requests and one business day for urgent requests; New Jersey Respect for Physicians Act - requiring insurers to respond with determinations within forty-eight hours for requests for prior authorization of health care services | ||
| NEW MEXICO | New Mexico Statutes, Chapter 59A - Insurance Code, § 59A-22B-5 – Prior Authorization Requirements | https://nmonesource.com/nmos/nmsa/en/item/4438/index.do#!fragment/zoupio-_Toc91758942/BQCwhgziBcwMYgK4DsDWszIQewE4BUBTADwBdoAvbRABwEtsBaAfX2zgE4BGAdgFYAHBwAsAJgCUAGmTZShCAEVEhXAE9oAcg2SIhMLgRKV6rTr0GQAZTykAQuoBKAUQAyTgGoBBAHIBhJ5KkYABG0KTs4uJAA | Requires insurers to make determinations within twenty-four hours for medically urgent requests and within seven days within for all other requests; requires denials based on medical necessity to be reviewed by a health care professional with knowledge or who consults with a specialist who has knowledge of the condition or disease of the patient; provides for expedited independent external review of denied appeals to the insurer. | |||||
| NEW YORK | New York Insurance Law § 3238 – Pre-Authorization of Health Care Services, New York Public Health Law § 4902 – Utilization Review Program Standards, New York Public Health Law § 4903 – Utilization Review Determinations, New York Public Health Law § 4910 - Right to External Review. | https://www.nysenate.gov/legislation/laws/ISC/3238 | Requires determination within three business days of receipt of complete request and information; requires insurers to publish policies, procedures, and clinical review criteria for patients and health care providers; requires insurers to make determinations regarding appeals of adverse determinations within one business day of receipt; requires insurers to submit to external independent review of adverse coverage determinations. | S7297 (2025) Relates to prior authorization and payments from the medical indemnity fund | https://www.nysenate.gov/legislation/bills/2025/S5710? | Utilization review must be based on evidence-based and peer-reviewed clinical criteria. Also tightens standards around PA and formulary changes. | ||
| NORTH CAROLINA | North Carolina General Statutes: § 58-50-61 – Utilization Review, § 58-50-62 – Insurer Grievance Procedures, § 58-50-80 Standard External Review, § 58-3-191 – Managed Care Reporting and Disclosure Requirements, § 58-3-200 Miscellaneous Insurance and Managed Care Coverage Provisions | https://www.ncleg.gov/Laws/GeneralStatuteSections/Chapter58 | Requires determination within 3 business days of receipt of information; prohibits insurers from retroactively denying authorization except if authorization was based on known material misrepresentation; provides for independent external review of adverse coverage decisions by state review board when patient has exhausted all internal appeals procedures. | HB 434 - Lower Health Care Costs | https://www.ncleg.gov/BillLookup/2025/H434 | Urgent prior authorization decisions required within 24 hours (down from three business days), insurers must publish online a list of services needing prior authorization; requires insurance-employed review physicians to be licensed in NC and of the same specialty as the requesting provider; prohibits new PAs for services where providers have had an 80% approval rate in the past year. | ||
| NORTH DAKOTA | ||||||||
| OHIO | Ohio Revised Code, Title 39 - Insurance, Chapter 3923 - Accident and Sickness Insurance, § 3923.041 - Provisions Applicable When Policy Contains Prior Authorization Requirement | https://codes.ohio.gov/ohio-revised-code/section-3923.041 | Requires determination within forty-eight hours for urgent requests and appeals and within ten calendar days for nonurgent requests and appeals; requires authorizations related to chronic conditions to be valid for at least twelve months; requires availability of independent external review for adverse coverage determinations; requires insurers to make all of its prior authorization requirements, including specific information a patient or provider must submit to obtain approval and which services or drugs to which a prior authorization requirement exists, available on its website. | HB 220 - To amend sections 1751.72, 3923.041, and 5160.34 of the Revised Code regarding health insurance and Medicaid program prior authorization requirements. | https://www.legislature.ohio.gov/legislation/136/hb220 | Would expand prior authorizationprotections to Medicaid recipients. | ||
| OKLAHOMA | Oklahoma Statutes Title 36. Insurance, §36-6570.8 - Time frame in which prior authorization may not be altered — Contracted payment rate requirement and exceptions; §36-6570.9. Treatment of chronic conditions — Validity period for prior authorization of inpatient and non-inpatient care. | https://law.justia.com/codes/oklahoma/title-36/section-36-6570-8/ | Prior authorization cannot be revoked, limited, or restricted if care was provided within 45 business days of approval unless the patient was ineligible on the service date; providers must still be paid the contracted rate unless exclusions apply; prior authorization for non-hospital care related to chronic conditions must remain valid for at least 6 months unless clinical criteria change; prior authorization for inpatient acute care for chronic conditions must remain valid for at least 14 days. | Oklahoma Statutes Title 63. Public Health and Safety §63-2550.4. Nonformulary or prior-authorized drugs - Approval. (managed care plans must approve or deny prior authorizations requests within 24 hours or issue a 72-hour supply and respond within that period; failure to respond results in automatic approval, with standard cost-sharing; providers and enrollees must receive prior authorization process details upon enrollment and when changes occur) | https://law.justia.com/codes/oklahoma/title-63/section-63-2550-4/ | |||
| OREGON | Oregon Revised Statutes, Title 56 Insurance,§§ 743.035, 743B.001, 743B.250, 743B.256, 743B.420, 743B.423, and 743B.602 | https://oregon.public.law/statutes/ors_title_56 | Requires insurers to provide written summary of information that the information that the insurer may consider in its utilization review of a particular condition upon request; requires insurers to provide an independent external review of adverse coverage decisions; prohibits insurers from changing prior authorization decisions made up to sixty days prior to the date service is provided unless there was misrepresentation; requires determination of nonemergency requests within two business days of receipt; prior authorizations must be valid for at least sixty days or the reasonable duration of treatment for medical services and for one year for prescription drugs. | |||||
| PENNSYLVANIA | Pennsylvania Code, Chapter 9, Title 38, § 9.707 - External grievance process | https://www.pacodeandbulletin.gov/Display/pacode?file=/secure/pacode/data/028/chapter9/s9.707.html&d=reduce#:~:text=28%20Pa.,provider%20to%20file%20the%20grievance. | Creates an external grievance process that may be used for prior authorization denials. | |||||
| *PUERTO RICO | ||||||||
| RHODE ISLAND | Rhode Island General Laws Title 28 Chapter 18.9 Benefit Determination and Utilization Review Act §§ 28-18.9-1 to -15 | http://webserver.rilegislature.gov/Statutes/TITLE27/27-18.9/INDEX.htm | Requires determination within seventy-two hours for urgent requests and within fifteen calendar days for nonurgent requests; requires determination upon appeal within seventy-two hours for urgent appeals and within thirty calendar days for nonurgent appeals; prohibits insurers from making a determination on an appeal unless an appropriately qualified provider had made a direct communication with the patient's provider; requires insurers to provide clinical criteria for determinations upon request; requires insurers to submit to external review by an independent review organization after patient exhausts the final internal level of appeal. | |||||
| SOUTH CAROLINA | South Carolina Laws, Title 44 - Health, Chapter 6 - Department of Health and Human Services, Articl 1 - General Provisions, § 44-6-1040, §44-6-1050 | https://www.scstatehouse.gov/query.php?search=DOC&searchtext=PRIOR%20AUTHORIZATION&category=CODEOFLAWS&conid=72420008&result_pos=0&keyval=854&numrows=10 | For Medicaid recipients: prior authorization requests for prescription drugs must be determined within 24 hours; 72-hour emergency supplies of drugs may be dispensed to provide additional time to obtain prior authorization; prior authorization approvals are for drug not prescription; denials may be appealed. | |||||
| SOUTH DAKOTA | South Dakota Codified Laws, Title 58 - Insurance, Chapters 17H and 17G, § 58-17G-4, § 58-17H-5 | https://sdlegislature.gov/Statutes/58 | Requires there to be a process and description of an easily accessible method to request exceptions and prior authorizations for prescription drugs; requires insurers to cover emergency services without prior authorization | |||||
| TENNESSEE | Tennessee Code, Title 56 - Insurance, Chapter 7 - Policies and Policyholders, Part 37 - Prior Authorization Fairness Act, §§ 56-7-3701 to 3722 | https://advance.lexis.com/documentpage/?pdmfid=1000516&crid=5b863c01-457a-4c8c-b0dc-76d7f3f7a984&nodeid=ACDAAGAAHAAB&nodepath=/ROOT/ACD/ACDAAG/ACDAAGAAH/ACDAAGAAHAAB&level=4&haschildren=&populated=false&title=56-6-701.%20Short%20title.&config=025054JABlOTJjNmIyNi0wYjI0LTRjZGEtYWE5ZC0zNGFhOWNhMjFlNDgKAFBvZENhdGFsb2cDFQ14bX2GfyBTaI9WcPX5&pddocfullpath=/shared/document/statutes-legislation/urn:contentItem:4WYH-TR70-R03M-J206-00008-00&ecomp=_g1_kkk&prid=2cf47394-31cb-433e-bf63-5a9d13d1dd5a | Requires adverse prior authorization decisions include explanation of decisions and appeal instructions; requires appeals to be reviewed by a physician in the same or similar specialty as one who typically manages the conditions; prior authorization requests must be decided within 7 days for nonurgent requetss and 72 hours for urgent care; prior authorization may not be required for emergency services; prior authorization for services or drugs related to chronic conditions remain valid for 6 months; insurers must maintain a complete list of services that require prior authorization; prior authorizations for services are valid for 6 months; prior authorization may not be required for prescription drugs used to treat opioid use disorder; insurers must provide notice to any changes in prior authorization requirements; existing prior authorizations must be honored for 90 days when a patient changes health plans; incidental services to those granted prior authorization must also be covered; prior authorization requirements must be readily accessible on an insurer's website. | |||||
| TEXAS | Texas Statutes, Insurance Code, Title 8 - Health Insurance and Other Health Coverages, Subtitle A - Health Coverage in General, Chapter 1222 - Preauthorization for Medical or Health Care | https://statutes.capitol.texas.gov/Docs/IN/htm/IN.1222.htm | Plans that require preauthorization must offer a renewal process; healthcare providers may request renewal at least 60 days before the existing preauthorization expires; insurers must review renewal requests before the existing authorization expires. | |||||
| UTAH | ||||||||
| VERMONT | Vermont Statutes Title 18 § 9418b – Prior Authorization, Vermont Statutes Title 8 § 4089i – Prescription Drug Coverage | https://legislature.vermont.gov/statutes/section/18/221/09418b | Requires insurers to pay for authorized services unless there was no coverage or the determination was based on fraud or materially inaccurate information; requires determination within forty-eight hours for urgent requests and within two business days for nonurgent requests; requires insurers to annually review and remove prior authorization requirements that are no longer justified. | 2021–2022 House Bill 102 | https://legislature.vermont.gov/Documents/2022/Docs/BILLS/H-0102/H-0102%20As%20Introduced.pdf | Proposing elimination of prior authorization requirements for services that meet a certain annual approval rate | ||
| VIRGINIA | Virginia Code, title 38.2 - Insurance, Chapter 34 - Provisions Relating to Accident and Sickness Insurance, § 38.2-3407.15:2 – Required Provisions Regarding Prior Authorization and required provisions regarding prior authorization for drug benefits | https://law.lis.virginia.gov/vacode/title38.2/chapter34/ | Goes into effect on January 1, 2027: Requires determination within twenty-four hours for urgent drug requests and within two business days for non-urgent drug requests; requires insurers to honor prior authorization for drugs from patient's previous insurer for thirty days; requires insurers to honor prior authorizations for drugs regardless of change of dosage if new dosage is consistent with FDA labelled dosages. | |||||
| WASHINGTON | Washington Administrative Code § 284-43-2050 – Prior Authorization Process, Revised Code of Washington § 48.43.016: Utilization Management Standards, -.535 Independent Review of Health Care Disputes, -.525 Prohibition Against Retrospective Denial , -.420 Prescription Drug Utilization Management | https://apps.leg.wa.gov/WAC/default.aspx?cite=284-43-2050 | Requires insurers to post prior authorization standards and criteria for medical necessity decisions on their website; requires determination within five calendar days for nonurgent medical service requests and within two calendar days for urgent medical service requests; requires determination within three business days for nonurgent prescription drug requests and within one business day for urgent prescription drug requests; prohibits insurers from requiring prior authorization for emergencies; prohibits retrospective denial of authorized health care; requires insurers to permit patients to seek review by an independent external review organization regarding adverse benefit decisions once patient has exhausted internal appeals. | |||||
| WEST VIRGINIA | West Virginia Code, Chapter 33 - Insurnace: §33-15-4s; §33-16-3dd; §33-24-7s; §33-25-8p; §33-25A-8s | https://code.wvlegislature.gov/33/ | Requires determination within seven days for nonurgent requests and within two days for urgent requests; requires prior authorization for services provided in state to remain valid for at least three months; permits health care providers to obtain a peer review of denied prior authorization requests with a health care provider in similar specialty, education, and background; insurers may only require one prior authorization for one episode of care. | |||||
| WISCONSIN | Wisconsin Statutes: § 632.85 – Prior Authorization for Emergency Medical Conditions, § 632.855 – Experimental Treatment | https://docs.legis.wisconsin.gov/statutes/statutes/632/vi/85 | Prohibits insurers from requiring prior authorization for emergency services; requires determination within five working days for experimental treatment authorization requests. | |||||
| WYOMING | Wyoming Statutes Annotated, Title 26 - Insurance Code, Chapter 55 - Ensuring Transparency in Prior Authorization Act, §§ 26-55-101 to 113 | https://advance.lexis.com/container?config=00JAAzZmQ5YjBjOC1hNDdjLTQxNGMtYmExZi0wYzZlYWIxMmM5YzcKAFBvZENhdGFsb2cJAHazmy52H3XVa9c97KcS&crid=b1154f3b-b0d0-42db-ae5a-acc4b56d9b1f | Insurers shall make prior authorization requirements easily accessible on websites; notice of new prior authorization requirements must be provided at least 60 days in advance; adverse determinations must be made, and any appeals reviewed, by a physician who has sufficient medical knowledge in applicable practice area or specialty; providers may request a discussion with insurer following an adverse prior authorization decision; prior authorization requests must be decided within 5 days for nonurgent services and within 72 hours for urgent services; prohibits prior authorization for medications for opioid use disorder; prior authorizations for outpatient services and prescription drugs must be valid for at least 1 year; prior authorizations may not be revoked, limited, conditioned or restricted if approved services provided within 45 days of obtaining approval; prior authorizations must be honored for 90 days following enrollment in a new plan; prior authorization may not be required for the first 12 rehabilitative or habilitative services. | |||||
| *GUAM | ||||||||
| LAST UPDATE | 8/2025 | 8/2025 | 8/2025 | 9/2022 |