Adds to existing law to establish the Idaho Prior Authorization Reform Act.

LEGISLATURE OF THE STATE OF IDAHO
Sixty-eighth Legislature Second Regular Session - 2026
IN THE HOUSE OF REPRESENTATIVES
HOUSE BILL NO. 841
BY WAYS AND MEANS COMMITTEE
AN ACT	1
RELATING TO HEALTH INSURANCE; AMENDING TITLE 41, IDAHO CODE, BY THE ADDITION	2
OF A NEW CHAPTER 35, TITLE 41, IDAHO CODE, TO ESTABLISH THE IDAHO PRIOR	3
AUTHORIZATION REFORM ACT, TO PROVIDE A SHORT TITLE, TO PROVIDE THE PUR-	4
POSE OF THE CHAPTER, TO PROVIDE FOR APPLICABILITY AND SCOPE, TO DEFINE	5
TERMS, TO PROVIDE FOR DISCLOSURE AND REVIEW OF PRIOR AUTHORIZATION RE-	6
QUIREMENTS, TO PROVIDE FOR PRIOR AUTHORIZATION APPLICATION PROGRAMMING	7
INTERFACE, TO PROVIDE FOR STANDARD PRIOR AUTHORIZATIONS, TO PROVIDE	8
FOR EXPEDITED PRIOR AUTHORIZATIONS, TO PROVIDE FOR NOTIFICATIONS FOR	9
ADVERSE DETERMINATIONS, TO PROVIDE FOR PERSONNEL QUALIFIED TO REVIEW	10
APPEALS, TO PROVIDE FOR INSURER REVIEW OF PRIOR AUTHORIZATION REQUIRE-	11
MENTS, TO PROVIDE FOR REVOCATION OF PRIOR AUTHORIZATIONS, TO PROVIDE	12
FOR THE LENGTH OF APPROVALS, TO PROVIDE FOR APPROVALS FOR CHRONIC CONDI-	13
TIONS, TO PROVIDE FOR CONTINUITY OF PRIOR APPROVALS, TO PROVIDE FOR EN-	14
FORCEMENT AND ADMINISTRATION, TO PROVIDE FOR REPORTS TO THE DEPARTMENT	15
OF INSURANCE, TO PROVIDE FOR FALSE REQUESTS FOR PRIOR AUTHORIZATION, TO	16
PROVIDE FOR A DE MINIMIS PRIOR AUTHORIZATION UTILIZATION EXEMPTION, AND	17
TO PROVIDE RULEMAKING AUTHORITY; AND PROVIDING AN EFFECTIVE DATE.	18
Be It Enacted by the Legislature of the State of Idaho:	19
SECTION 1. That Title 41, Idaho Code, be, and the same is hereby amended	20
by the addition thereto of a NEW CHAPTER, to be known and designated as Chap-	21
ter 35, Title 41, Idaho Code, and to read as follows:	22
CHAPTER 35	23
IDAHO PRIOR AUTHORIZATION REFORM	24
41-3501. SHORT TITLE. This chapter shall be known and may be cited as	25
the "Idaho Prior Authorization Reform Act."	26
41-3502. PURPOSE. The purpose of this chapter is to:	27
(1) Protect the health care provider-patient relationship from unrea-	28
sonable third-party interference;	29
(2) Prevent prior authorization programs from hindering the indepen-	30
dent medical judgment of a physician or other health care provider; and	31
(3) Ensure the transparency of a fair and consistent process for health	32
care providers and their patients.	33
41-3503. APPLICABILITY AND SCOPE. This chapter applies to every	34
health benefit plan, as defined in section 41-5903, Idaho Code, to all is-	35
suers of health benefit plans, to all incorporated or stand-alone dental	36
benefit plans, and to all utilization reviews and utilization review orga-	37
nizations, as defined in section 41-5903, Idaho Code, except for employee	38
or employer self-insured health benefit plans under the federal employee	39

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retirement income security act of 1974, health care provided pursuant to	1
worker's compensation law, or prescription drugs, biologics, biosimilars,	2
and pharmaceutical medicines. This chapter does not diminish the duties and	3
responsibilities under other federal or state law or rules promulgated under	4
those laws applicable to a health insurer, health insurance issuer, health	5
benefit plan, utilization review plan, or utilization review organization.	6
41-3504. DEFINITIONS. For the purposes of this chapter:	7
(1) "Adverse determination" means a determination by a health insur-	8
ance issuer that, based on the information provided, a pre-service request	9
for a benefit under the health insurance issuer's health benefit plan upon	10
application of any utilization review technique does not meet the health	11
insurance issuer's requirements for medical necessity, appropriateness,	12
health care setting, level of care, or effectiveness or is determined to be	13
experimental or investigational, and the requested benefit is therefore	14
denied.	15
(2) "Appeal" means a formal request, either orally or in writing, to re-	16
consider an adverse determination.	17
(3) "Approval" means a determination by a health insurance issuer that	18
a health care service has been reviewed and, based on the information pro-	19
vided, satisfies the health insurance issuer's requirements for medical ne-	20
cessity and appropriateness.	21
(4) "Clinical review criteria" means the written screening procedures,	22
decision abstracts, clinical protocols, and practice guidelines used by a	23
health insurance issuer to determine the necessity and appropriateness of	24
health care services.	25
(5) "Complete prior authorization request" means a prior authorization	26
request that:	27
(a) Is submitted by a health care professional or health care provider	28
in accordance with the standardized electronic prior authorization	29
process required by this chapter, if applicable;	30
(b) Includes all clinical documentation, diagnostic results, and other	31
information reasonably required by the health insurance issuer's pub-	32
licly disclosed clinical review criteria in effect at the time the re-	33
quest is submitted;	34
(c) Requires no additional information from the enrollee, the	35
provider, or a third party that is reasonably necessary to adjudicate	36
the request; and	37
(d) Complies with the health insurance issuer's published prior autho-	38
rization submission standards in effect at the time the request is sub-	39
mitted.	40
(6) "Dentist" means any person with a valid doctor of dental surgery,	41
doctor of medicine in dentistry, or doctor of dental medicine degree.	42
(7) "Department" means the Idaho department of insurance.	43
(8) "Emergency medical condition" means a medical condition manifest-	44
ing itself by acute symptoms of sufficient severity, including but not lim-	45
ited to severe pain, such that a prudent layperson who possesses an average	46
knowledge of health and medicine could reasonably expect the absence of im-	47
mediate medical attention to result in:	48

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(a) Placing the health of the individual or, with respect to a pregnant	1
woman, the health of the woman or her unborn child, in serious jeopardy;	2
(b) Serious impairment to bodily functions; or	3
(c) Serious dysfunction of any bodily organ or part.	4
(9) "Emergency services" means health care items and services fur-	5
nished or required to evaluate and treat an emergency medical condition.	6
(10) "Enrollee" means any person and the person's dependents enrolled	7
in or covered by a health care plan.	8
(11)(a) "Expedited prior authorization request" means a pre-service or	9
concurrent care claim for medical care or treatment for which applica-	10
tion of the time periods for making a non-expedited prior authorization	11
could, in the opinion of a treating health care professional or health	12
care provider with knowledge of the enrollee's medical condition:	13
(i) Seriously jeopardize the life or health of the enrollee or the	14
ability of the enrollee to regain maximum function;	15
(ii) Subject the enrollee to severe pain that cannot be adequately	16
managed without the care or treatment that is the subject of the	17
authorization request; or	18
(iii) Lead to likely onset of an emergency medical condition if the	19
service is not rendered during the time period to render a prior	20
authorization determination for an urgent medical service.	21
(b) "Expedited prior authorization request" does not apply to emer-	22
gency services.	23
(12) "Health care professional" means a physician, a registered pro-	24
fessional nurse, a dentist, or another individual appropriately licensed or	25
registered to provide health care services.	26
(13) "Health care provider" means any physician, dentist, hospital, am-	27
bulatory surgery center, or other person or facility that is licensed or oth-	28
erwise authorized to deliver health care services.	29
(14) "Health care service" means any services or level of services in-	30
cluded in the furnishing of medical or dental care to an individual or the	31
hospitalization incident to the furnishing of such care, as well as the fur-	32
nishing of any other services to any person for the purpose of preventing,	33
alleviating, curing, or healing human illness or injury, including behav-	34
ioral health, mental health, and home health, and pharmaceutical services,	35
products, and medications.	36
(15) "Health insurance issuer" means the issuer of a health benefit plan	37
or dental benefit plan.	38
(16) "Medically necessary" means care that a health care professional	39
exercising prudent clinical judgment would provide to a patient for the pur-	40
pose of preventing, diagnosing, or treating an illness, injury, disease, or	41
its symptoms and that is:	42
(a) In accordance with generally accepted standards of medical prac-	43
tice or dental practice;	44
(b) Clinically appropriate in terms of type, frequency, extent, site,	45
and duration and considered effective for the patient's illness, in-	46
jury, or disease;	47
(c) Focused on what is best for the patient's health outcome; and	48

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(d) Not primarily for the convenience of the patient, treating physi-	1
cian, other health care professional, caregiver, family member, or	2
other interested party.	3
(17) "Physician" means any person with a valid doctor of medicine, doc-	4
tor of osteopathy, or doctor of podiatry degree.	5
(18) "Prior authorization" means the process by which a health insur-	6
ance issuer determines the medical necessity and medical appropriateness of	7
an otherwise covered health care service before the rendering of such health	8
care service. While not requiring explicit approval, any notification re-	9
quired of an enrollee, health care professional, or health care provider by	10
the health insurance issuer before, at the time of, or concurrent to provid-	11
ing a health care service shall be included within the definition of "prior	12
authorization." Any pre-service review that is used to evaluate clinical ne-	13
cessity, regardless of the terminology used to describe such pre-service re-	14
view, falls within this definition, including but not limited to predetermi-	15
nation, pretreatment, and preauthorization.	16
(19) "Urgent health care services" means those services that, if not	17
provided to an enrollee, could seriously jeopardize the enrollee's life,	18
health, or ability to regain maximum function.	19
(20) "Utilization review organization" has the meaning given to that	20
term in section 41-5903, Idaho Code.	21
41-3505. DISCLOSURE AND REVIEW OF PRIOR AUTHORIZATION REQUIRE-	22
MENTS. (1) A health insurance issuer shall maintain a complete list of	23
services for which prior authorization is required, including for all ser-	24
vices where prior authorization is performed by an entity under contract	25
with the health insurance issuer.	26
(2) A health insurance issuer shall make any current prior authoriza-	27
tion requirements and restrictions, including the written clinical review	28
criteria, readily accessible and conspicuously posted on its website or	29
online portal to enrollees, health care professionals, and health care	30
providers. Content published by a third party and licensed for use by a	31
health insurance issuer may be made available through the health insurance	32
issuer's secure, password-protected website or online portal as long as the	33
access requirements of the website do not unreasonably restrict access.	34
Requirements shall be described in detail, written in easily understandable	35
language, and readily available to the health care professional and health	36
care provider at the point of care. The website or online portal shall indi-	37
cate for each service subject to prior authorization:	38
(a) The date on which prior authorization became required for policies	39
issued or health benefit plan documents delivered in Idaho, including	40
the effective dates and the termination dates, if applicable, in Idaho;	41
(b) The date on which the Idaho-specific requirement was listed on the	42
website or online portal of the health insurance issuer;	43
(c) If applicable, the date on which the prior authorization require-	44
ment was removed for Idaho; and	45
(d) If applicable, access to a standardized electronic prior autho-	46
rization request transaction process.	47
(3) The clinical review criteria must:	48

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(a) Be consistent with nationally accepted standards generally recog-	1
nized by physicians and health care providers practicing in relevant	2
medical and clinical specialties except where state law provides its	3
own standard;	4
(b) Be developed in accordance with the current standards of a national	5
medical accreditation entity;	6
(c) Ensure quality of care and access to needed health care services;	7
(d) Be based on evidence from sources, including peer-reviewed scien-	8
tific studies;	9
(e) Be sufficiently flexible to allow deviations from norms when justi-	10
fied on a case-by-case basis; and	11
(f) Be evaluated and updated at least annually under the direction of a	12
physician who:	13
(i) Possesses a current, valid, and unrestricted license to prac-	14
tice medicine in Idaho or in a state with substantially similar li-	15
censing requirements; and	16
(ii) Has knowledge of the standard of care in the community where	17
care is proposed to be provided.	18
(4) A health insurance issuer shall not deny a claim for failure to ob-	19
tain prior authorization if the prior authorization requirement was not in	20
effect on the date of service or if the claim or prior authorization require-	21
ments were not publicly disclosed by the plan on the health insurance is-	22
suer's website, online portal, or other materials.	23
(5) If a health insurance issuer intends either to implement a new prior	24
authorization requirement or restriction or to amend an existing require-	25
ment or restriction, the health insurance issuer shall provide impacted	26
enrollees, contracted health care professionals, and contracted health care	27
providers of enrollees written notice of the new or amended requirement no	28
less than sixty (60) days before the requirement or restriction is imple-	29
mented. Written notice may take the form of a conspicuous notice posted	30
on the health insurance issuer's public website or online portal for con-	31
tracted health care professionals and contracted health care providers or	32
email notice to health care professionals or health care providers. A health	33
insurance issuer shall provide email notices to all impacted enrollees and	34
to health care professionals or health care providers if the health care	35
professional or health care provider has requested to receive the notice	36
through email. A new or amended requirement shall not be implemented unless	37
the health insurance issuer's website or online portal has been updated to	38
reflect the new or amended requirement or restriction. Written notice of a	39
new, amended, or restricted prior authorization requirement may be provided	40
less than sixty (60) days in advance of implementation if a health insurance	41
issuer determines and contemporaneously notifies the department in writing	42
that:	43
(a) The health insurance issuer has identified fraudulent or abusive	44
practices related to the health care service;	45
(b) The health care service is unavailable or scarce, necessitating the	46
use of an alternative health care service;	47
(c) The health care service is newly introduced to the health care mar-	48
ket and a delay in providing coverage for the health care service would	49
not be in the best interests of enrollees;	50

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(d) The health care service is the subject of a clinical trial autho-	1
rized by the United States food and drug administration;	2
(e) Changes to the health care service or its availability are other-	3
wise required by law to be made by the health insurance issuer in less	4
than sixty (60) days; or	5
(f) The prior authorization requirement is being removed.	6
(6) Health insurance issuers using prior authorization shall make sta-	7
tistics available regarding prior authorization approvals and denials on	8
their website or online portal in a readily accessible format. The reporting	9
requirements of this subsection shall be implemented in a manner consistent	10
with the public reporting requirements established under the centers for	11
medicare and medicaid services (CMS) interoperability and prior authoriza-	12
tion final rule (CMS-0057-F), as amended, to the extent applicable.	13
(7) The implementation requirements of this section shall commence by	14
January 1, 2027. Health insurance issuers may comply with the implementa-	15
tion requirements of this section in phases, consistent with applicable fed-	16
eral interoperability timelines.	17
41-3506. PRIOR AUTHORIZATION APPLICATION PROGRAMMING INTERFACE. (1)	18
If a health insurance issuer requires prior authorization of a health care	19
service, the issuer or its contracted utilization review organization	20
shall, to the extent required under applicable federal interoperability	21
requirements, and by January 1, 2027, implement and maintain a prior autho-	22
rization application programming interface (API).	23
(2) The API shall:	24
(a) Conform to the applicable interoperability standards adopted by	25
the centers for medicare and medicaid services (CMS) in the CMS inter-	26
operability and prior authorization final rule (CMS-0057-F), including	27
health level 7 fast healthcare interoperability resources release	28
4.0.1 or a successor version adopted by CMS;	29
(b) Be capable of identifying, for items and services excluding pre-	30
scription drugs unless otherwise required by federal law, whether prior	31
authorization is required;	32
(c) Identify payer-specific documentation requirements for each item	33
or service that requires prior authorization;	34
(d) Support the electronic creation and exchange of prior authoriza-	35
tion requests and responses between health care professionals, health	36
care providers, and the health insurance issuer; and	37
(e) Be implemented in a manner that does not disrupt compliance with	38
federal interoperability requirements.	39
(3) A health insurance issuer may use an updated version of a required	40
interoperability standard if such use is consistent with federal law and	41
does not disrupt an end user's ability to access required data.	42
(4) Nothing in this section shall require the creation of an Idaho-spe-	43
cific electronic prior authorization.	44
(5) For the purposes of this chapter, a prior authorization request	45
shall be deemed received only upon submission of a complete prior authoriza-	46
tion request.	47
(a) A request shall be considered complete when the health insurance	48
issuer has received all documentation and information reasonably nec-	49

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essary to make a determination under the terms of the health benefit	1
plan.	2
(b) A prior authorization request shall not fail to meet the definition	3
of a complete prior authorization request due to minor clerical or tech-	4
nical errors that do not materially affect the ability of the health in-	5
surance issuer to make a determination.	6
(c) A prior authorization request shall be presumed complete unless the	7
health insurance issuer provides written notice within one (1) business	8
day of receipt specifying with particularity any additional informa-	9
tion reasonably necessary to adjudicate the request.	10
41-3507. STANDARD PRIOR AUTHORIZATIONS. (1) If a health insurance	11
issuer requires prior authorization of a health care service, the health	12
insurance issuer shall render a decision and notify the enrollee and the en-	13
rollee's health care professional or health care provider as expeditiously	14
as the enrollee's condition requires but no later than seven (7) calen-	15
dar days after receipt of a complete prior authorization request, unless a	16
longer time frame is required under applicable federal law. Requests for	17
additional information must be reasonably necessary to adjudicate the prior	18
authorization request. As used in this section, "additional information"	19
may include the results of any face-to-face clinical evaluation, a second	20
opinion, or any other clinical information that is directly applicable to	21
the requested service as may be required.	22
(2) If a health insurance issuer determines that a prior authorization	23
request is incomplete, the health insurance issuer shall notify the health	24
care professional or health care provider within one (1) business day and	25
shall specify in writing the information reasonably necessary to complete	26
the request. The health insurance issuer may request additional information	27
only once per prior authorization request unless the health care provider	28
submits materially new clinical information.	29
41-3508. EXPEDITED PRIOR AUTHORIZATIONS. (1) If requested by a treat-	30
ing health care professional or health care provider for an enrollee, a	31
health insurance issuer shall render a decision concerning urgent health	32
care services as expeditiously as the enrollee's condition requires, but	33
no later than seventy-two (72) hours after receipt of a complete expedited	34
prior authorization request, unless a longer time frame is required pursuant	35
to applicable federal law.	36
(2) To facilitate the rendering of a prior authorization determina-	37
tion pursuant to this section, a health insurance issuer shall establish a	38
mechanism to ensure health care professionals have access to appropriately	39
trained and licensed physicians preferably but not necessarily of the same	40
specialty for consultation, designated by the health insurance issuer to	41
make such determinations for prior authorization concerning urgent care	42
services.	43
41-3509. NOTIFICATIONS FOR ADVERSE DETERMINATIONS. If a health in-	44
surance issuer makes an adverse determination, the health insurance issuer	45
shall include the following in the notification to the enrollee and the en-	46
rollee's health care professional or health care provider:	47

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(1) The reasons for the adverse determination and related evi-	1
dence-based criteria, including a description of any missing or insuffi-	2
cient documentation;	3
(2) The right to appeal the adverse determination;	4
(3) Instructions on how to file the appeal;	5
(4) Additional documentation necessary to support the appeal; and	6
(5) The right to request an independent external review pursuant to the	7
provisions of chapter 59, title 41, Idaho Code.	8
41-3510. PERSONNEL QUALIFIED TO REVIEW APPEALS. A health insurance	9
issuer shall ensure that all appeals are peer reviewed by an appropriate	10
licensed health care professional in the same or substantially similar field	11
or specialty. The reviewing health care professional shall:	12
(1) Possess a current and valid nonrestricted license to practice	13
medicine with substantially similar licensing requirements to this state;	14
(2) Be certified by the American board of medical specialties or the	15
American osteopathic association within the relevant specialty of a physi-	16
cian who typically manages the medical condition or disease;	17
(3) Have training, knowledge, or experience of providing the health	18
care services under appeal;	19
(4) Not have been directly involved in making the adverse determina-	20
tion; and	21
(5) Consider all known clinical aspects of the health care service un-	22
der review, including a review of all pertinent medical records provided to	23
the health insurance issuer or health care provider, the health plan's clin-	24
ical guidelines, and peer-reviewed scientific studies.	25
41-3511. INSURER REVIEW OF PRIOR AUTHORIZATION REQUIREMENTS. A health	26
insurance issuer shall periodically review its prior authorization require-	27
ments and consider removal of prior authorization requirements.	28
41-3512. REVOCATION OF PRIOR AUTHORIZATIONS. (1) A health insurance	29
issuer may not revoke or further limit, condition, or restrict a previously	30
issued prior authorization approval while it remains valid in accordance	31
with this chapter unless:	32
(a) The health insurance issuer has identified fraudulent or abusive	33
practices related to the health care service;	34
(b) The health care service is unavailable, necessitating the use of an	35
alternative health care service;	36
(c) The health care service is the subject of a new safety alert from the	37
United States food and drug administration or is in response to a public	38
health emergency;	39
(d) The change is based on nationally recognized generally accepted	40
standards developed in accordance with current standards of a national	41
medical accreditation entity or specialty society;	42
(e) Changes to the health care service or its availability are other-	43
wise required by law to be made by the health insurance issuer within	44
sixty (60) days; or	45
(f) There is a material change in clinical circumstances that is sup-	46
ported by documented medical evidence.	47

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(2) Notwithstanding any other provision of law, if a claim is properly	1
coded and timely submitted to a health insurance issuer, the health insur-	2
ance issuer shall make payment according to the terms of coverage on claims	3
for health care services for which prior authorization was required and ap-	4
proval received before the provision of health care services unless:	5
(a) It is determined that the enrollee's health care professional or	6
health care provider knowingly and without exercising prudent clinical	7
judgment provided health care services that required prior authoriza-	8
tion from the health insurance issuer or its contracted utilization re-	9
view organization without first obtaining prior authorization for such	10
health care services;	11
(b) It is timely determined that the health care services claimed were	12
not performed;	13
(c) It is timely determined that the health care services provided by	14
the enrollee's health care professional or health care provider were	15
contrary to the instructions of the health insurance issuer or its con-	16
tracted utilization review organization if contact was made between	17
such parties before the health care services being provided;	18
(d) It is timely determined that the person receiving such health care	19
services was not an enrollee of the health care plan; or	20
(e) The approval was based on a material misrepresentation by the en-	21
rollee, health care professional, or health care provider. As used in	22
this paragraph, "material" means a fact or situation that would have re-	23
sulted in a substantial change in the determination had it been accu-	24
rately disclosed in the submission.	25
(3) Nothing in this section shall preclude a health insurance issuer or	26
a utilization review organization from performing post-service reviews of	27
health care claims for purposes of payment integrity or for the prevention of	28
fraud, waste, or abuse.	29
41-3513. LENGTH OF APPROVALS. (1) A prior authorization approval	30
shall be valid for six (6) months after the date the health care profes-	31
sional or health care provider receives the prior authorization approval.	32
Provided, however, a health insurance issuer and an enrollee or enrollee's	33
health care professional may extend a prior authorization approval for a	34
longer period, by agreement.	35
(2) Nothing in this section shall require a policy or plan to cover any	36
care, treatment, or services for any health condition that the terms of cov-	37
erage otherwise completely exclude from the policy's or plan's covered ben-	38
efits without regard for whether the care, treatment, or services are medi-	39
cally necessary.	40
41-3514. APPROVALS FOR CHRONIC CONDITIONS. (1) If a health insurance	41
issuer requires a prior authorization for a recurring health care service	42
for the treatment of a chronic or long-term condition, the approval shall re-	43
main valid for the lesser of twelve (12) months from the date the health care	44
professional or health care provider receives the authorization approval or	45
the length of the treatment as determined by the patient's health care pro-	46
fessional. Provided, however, a health insurance issuer and an enrollee or	47

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the enrollee's health care professional may extend a prior authorization ap-	1
proval for a longer period, by agreement.	2
(2) Nothing in this section shall require a policy or plan to cover any	3
care, treatment, or services for any health condition that the terms of cov-	4
erage otherwise completely exclude from the policy's or plan's covered ben-	5
efits without regard for whether the care, treatment, or services are medi-	6
cally necessary.	7
41-3515. CONTINUITY OF PRIOR APPROVALS. (1) Upon receipt of informa-	8
tion documenting a prior authorization approval from the enrollee or from	9
the enrollee's health care professional or health care provider, a health	10
insurance issuer shall honor a prior authorization granted to an enrollee	11
from a previous health insurance issuer for at least the initial ninety (90)	12
days of an enrollee's coverage under a new health plan, subject to the terms	13
of the enrollee's coverage agreement.	14
(2) During the time period described in subsection (1) of this section,	15
a health insurance issuer may perform its own review to grant a prior autho-	16
rization approval, subject to the terms of the enrollee's coverage agree-	17
ment.	18
(3) Nothing in this chapter shall require a policy or plan to cover any	19
care, treatment, or services for any health condition that the terms of cov-	20
erage otherwise completely exclude from the policy's or plan's covered ben-	21
efits without regard for whether the care, treatment, or services are medi-	22
cally necessary.	23
(4) Nothing in this chapter shall prevent a health insurance issuer to	24
engage an enrollee with an option to consider clinically appropriate alter-	25
natives.	26
41-3516. ENFORCEMENT AND ADMINISTRATION. (1) In addition to the en-	27
forcement powers granted to it by law to enforce the provisions of this chap-	28
ter, the department is granted specific authority to issue a cease-and-de-	29
sist order or require a health insurance issuer or utilization review organ-	30
ization, or both, to submit a plan of correction for violations of this chap-	31
ter. Subject to rules promulgated by the department pursuant to chapter 52,	32
title 67, Idaho Code, and after proper notice and the opportunity for a hear-	33
ing, the department may impose on a health insurance issuer, health benefit	34
plan, or utilization review organization an administrative fine not to ex-	35
ceed ten thousand dollars ($10,000) per violation for failure to submit a re-	36
quested plan of correction, failure to comply with its plan of correction,	37
or repeated violations of this chapter. All fines collected by the depart-	38
ment pursuant to this section shall be deposited in the state general fund.	39
The department may also exercise all authority granted to it under the pro-	40
visions of chapter 59, title 41, Idaho Code, to deny or revoke approval of a	41
utilization review organization for a violation of this chapter.	42
(2) An enrollee or an enrollee's health care provider who has evidence	43
that the enrollee's health insurance issuer or health benefit plan is in	44
violation of the provisions of this chapter may file a complaint with the	45
department. The department shall review all complaints received and in-	46
vestigate all complaints that it deems to state a potential violation. The	47
department shall fairly, efficiently, and timely review and investigate	48

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complaints and shall provide the subject of the complaint an opportunity to	1
refute the evidence against it. Health insurance issuers, health benefit	2
plans, and utilization review organizations found to be in violation of this	3
chapter shall be penalized in accordance with this section.	4
(3) There shall be no private right of action under this chapter.	5
41-3517. REPORTS TO THE DEPARTMENT. (1) By June 1, 2027, and each June	6
thereafter, a health insurance issuer shall report to the department, on a	7
form issued by the department, the following aggregated trend data, de-iden-	8
tified of protected health information, related to the insurer's practices	9
and experience for the prior plan year for health care services submitted for	10
payment:	11
(a) The number of prior authorization requests;	12
(b) The percentage of prior authorization requests denied;	13
(c) The percentage of prior authorization appeals received;	14
(d) The percentage of adverse determinations reversed on appeal;	15
(e) The percentage of prior authorization requests that were not sub-	16
mitted electronically;	17
(f) As a percentage by service, the ten (10) health care services that	18
were most frequently denied through prior authorization; and	19
(g) The five (5) reasons prior authorization requests were most fre-	20
quently denied.	21
(2) All reports required by this section shall be considered public	22
records pursuant to chapter 1, title 74, Idaho Code, and the department shall	23
make all reports freely available to requesters and post all reports to its	24
public website without redactions.	25
41-3518. FALSE REQUESTS FOR PRIOR AUTHORIZATION. If a health insur-	26
ance issuer has clear and convincing evidence that a health care profes-	27
sional or health care provider has knowingly and willfully submitted false	28
or fraudulent requests for prior authorization to the health insurance is-	29
suer, the health insurance issuer shall notify and provide that information	30
to the department director. After receipt of such notification and infor-	31
mation, the director shall forward these reports to the board of medicine or	32
such other licensing agency with oversight of the health care professional	33
or health care provider and to the office of the prosecuting authority having	34
jurisdiction.	35
41-3519. DE MINIMIS PRIOR AUTHORIZATION UTILIZATION EXEMPTION. (1) A	36
health insurance issuer that, for the prior plan year, required prior autho-	37
rization for less than one percent (1%) of claims submitted for payment under	38
health benefit plans issued or delivered in Idaho may elect to be exempt from	39
the requirements of this chapter.	40
(2) The election shall be made by filing an annual attestation with the	41
department, in a form and manner specified by the department, demonstrating	42
that the health insurance issuer meets the threshold provided for in subsec-	43
tion (1) of this section.	44
(3) Upon request, the health insurance issuer shall provide records	45
reasonably necessary for the department to verify the attestation provided	46
for in subsection (2) of this section. If the department determines the	47

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health insurance issuer does not meet the threshold, the department may re-	1
voke the exemption and require compliance within a reasonable period.	2
41-3520. RULES. The department shall have the authority to promulgate	3
rules, subject to legislative approval, pursuant to the provisions of chap-	4
ter 52, title 67, Idaho Code, to govern the administration of this chapter.	5
SECTION 2. This act shall be in full force and effect on and after Jan-	6
uary 1, 2027.	7

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