Pennsylvania Prior Authorization Law

Overview

Pennsylvania Act 112 and HB 1285 (2023) set strict timelines for prior authorization decisions. Insurers must respond to standard requests within 5 business days and urgent requests within 48 hours. All denials require clinical rationale. Missed deadlines result in automatic approval of the requested service.

Key Requirements

1. Insurers must acknowledge PA requests within 24 hours and provide decision timeline.
2. Standard PA decisions within 5 business days; urgent decisions within 48 hours.
3. All PA denials must include specific clinical rationale tied to medical policy and the patient's presentation.
4. Providers may request expedited review if standard timeline is medically inappropriate.
5. Clear appeal procedures and external review access must accompany each denial.

Penalties and Enforcement

Insurers who miss PA deadlines or deny without clinical rationale face fines from the PA Insurance Department. Providers may bill at usual and customary rates if the insurer misses the decision deadline. Patients may seek external review. Repeat violations trigger license sanctions and increased penalties.

Appeals and Exceptions

Urgent PA requests are expedited based on clinical necessity. Denials may be appealed to the insurer's medical director within 10 business days. Providers and patients have the right to independent external review if internal appeals fail. Certain denial codes trigger automatic expedited review.

Interaction with Federal Law

Pennsylvania PA timelines align with federal standards. The 48-hour urgent requirement matches federal requirements. Pennsylvania's clinical rationale requirement exceeds federal standards. Providers benefit from Pennsylvania's stricter documentation requirements. NSA rules complement PA timelines.

Common Questions