Missouri Prior Authorization

Overview

Revised Statutes of Missouri Section 376.415 (2022 PA reform) establishes timelines and standards for prior authorization decisions. Insurers must respond to standard prior authorization requests within 3 business days of receiving complete clinical information and to urgent or expedited requests within 1 business day. Denial notices must include the specific clinical criteria that were not met and the evidence-based clinical rationale for the denial.

Key Requirements

1. Standard PA Response Timeline: Three business days from receipt of complete clinical information to approve, deny, or request additional information.
2. Urgent/Expedited PA Timeline: One business day for expedited requests where standard timeline could adversely affect patient care.
3. Emergency Exception: Prior authorization is not required for emergency services. Retrospective review is permitted only after stabilization.
4. Denial Notice Content: Denial notices must include the specific clinical criteria cited, the evidence-based or clinical rationale for the denial, and complete appeal instructions.
5. Internal Appeal Rights: Patients and providers have 30 days to file an internal appeal of any PA denial. Expedited appeals are decided within 3 business days.

Penalties and Enforcement

The Missouri Department of Insurance, Financial Institutions and Professional Registration (DIFP) enforces prior authorization requirements. Violations include missing response deadlines, issuing denials without adequate clinical rationale, and failing to provide appeal rights. Insurers in violation are subject to complaints, market conduct examinations, and civil penalties. DIFP has authority to require corrective action plans and assess fines.

Appeals and Exceptions

All patients and providers have the right to appeal any prior authorization denial. Internal appeals must be filed within 30 days of the denial and are decided within 30 days. Expedited internal appeals are decided within 3 business days. External review is not mandated by Missouri law but may be available through the insurer's voluntary process. Emergency services have no PA requirement.

Interaction with Federal Law

Federal regulations under CMS-0057-F beginning 2026-2027 establish federal prior authorization response timelines that apply to all plans. These federal rules establish a floor for patient protection that does not preempt stronger state requirements. Self-funded ERISA plans follow federal requirements; state-regulated plans must comply with both Missouri state law and federal standards.

Common Questions