What Physicians Need to Know Now About Senate Bill 225 Prior Authorization Reforms

After years of advocating for prior authorization reform, the efforts of Pennsylvania Medical Society (PAMED) and other stakeholders paid off when Senate Bill 225, also known as Act 146, was signed into law in November 2022.

Historically, prior authorizations have been used as a cost containment tool by health insurance plans to ensure the proposed treatment or medication is medically necessary. However, for patients and providers, prior authorizations delay treatment and create administrative burdens, making them a barrier to effective care. Act 146 standardizes the process to address some of these barriers.

Specifically, Act 146 requires Pennsylvania regulated healthcare insurers (insurers), Medical Assistance (MA), and Children’s Health Insurance Plans (CHIP) to create a provider portal to allow for the electronic submission of prior authorizations and to provide access to medical policies and information needed to request a peer-to-peer review. Regulated entities must also list on their publicly accessible website the health care services that require prior authorization.

Insurers/MA/CHIP are also required to follow “same or similar specialty requirements.” This means prior authorizations may only be denied after review by, or in consultation with, a licensed health care provider with appropriate training, knowledge or experience in the same or similar specialty as the provider.

Processing times is another hurdle that negatively impacts how quickly patients can receive care. Under Act 146,  MA/CHIP has 2 business days to communicate a decision once they receive all supporting information to complete the review. Insurers are subject to the following timelines:

• Urgent health care service – as soon as possible but not more 72 hours after submission. If related to an ongoing urgent health care service and the request is made at least 24 hours prior to reduction or termination of the treatment, within 24 hours.
• Non-urgent health care service – within 15 days of submission.
• Prescription drug or Step Therapy- if urgent then within 24 hours; all others within 2 business days but not more than 72 hours.

All requirements of Act 146 are currently in effect. Insurers/MA/CHIP were given 18 months from the effective date of the law (January 1, 2023) to comply with the provider portal requirements. The remainder of the law went into effect on January 1, 2024.

The Pennsylvania Insurance Department (PID) is the state agency responsible for ensuring that insurers/MA/CHIP comply with Act 146 to provide timely and fair reviews. Patients and providers who need assistance with enforcing any requirements in Act 146 may file a complaint with the PID.