Michigan legislature reforms prior authorization: 10 things for physicians to know

In April 2022, the Michigan legislature signed Public Act 60, creating prior authorization reform for patients and clinicians in the state. All provisions in the act are set to take effect on June 1. 

While the act does not repeal prior authorization, it aims to make the process faster, more effective and more transparent, according to an April 19 press release from the Michigan State Medical Society. 

The reforms apply to healthcare insurers and professionals with commercial insurance policies regulated by the Michigan Department of Insurance and Financial Services. They do not impact Medicaid, Medicare, Medicare Advantage or self-funded plans. 

Ten things to know about Michigan's new prior authorization rules, beginning June 1: 

1. Insurers must provide an online option for submitting prior authorization requests for any benefits, including prescription medications. 

2. Physicians and healthcare professionals must submit prior authorizations electronically, except for in instances of technological or electrical failure. 

3. Prior authorization approvals will be valid for 60 days, or the length of time that's clinically appropriate, whichever is longer. 

4. Urgent prior authorization requests have to be acted on within 72 hours or they are automatically approved. 

5. Non-urgent requests have to be acted on within nine days or they are automatically approved. 

6. If a denial is appealed, it must be reviewed by a licensed physician who is board certified in the same specialty as the service provided. 

7. Prior authorization requirements must be based on peer-reviewed clinical review criteria that takes into account atypical populations, reflects a community standard of care, is publicly available free of charge and is evaluated and updated at least annually. 

8. Prior authorization requirements and changes must be posted online within a specific timeline. 

9. If prior authorization is denied, healthcare professionals must be notified of the reason and given evidence-based criteria. 

10. Insurers must adopt a "gold card" program that promotes the modification of prior authorization requirements based on healthcare professionals' adherence to medical and quality guidelines.  

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