44-5441. Prior authorization; period of validity.
297 words·~1 min read·
/ne/chapter-44/44-5441A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
(1)Except as otherwise provided in this section, prior authorization shall be valid for at least one year from the date the utilization review agent approves the prior authorization request, except for a prescription drug that has a treatment schedule or dosing limitation from the federal Food and Drug Administration of less than one year.
(2)(a) If a prior authorization is required for inpatient care at a general acute hospital, the prior authorization shall remain valid for the length of stay approved by the utilization review agent.
(b)If the health care provider submits a timely request for the continuation of inpatient care, the utilization review agent shall respond to this request prior to the expiration of the current authorization for inpatient care.
(c)If a utilization review agent fails to respond to a timely request for the continuation of inpatient care prior to the termination of the previously approved length of stay, then the health carrier shall continue to compensate the health care provider at the contracted rate for inpatient care provided until the utilization review agent issues its determination on the prior authorization request.
(d)Nothing in this subsection shall be interpreted to prohibit a health care provider or enrollee from appealing an adverse determination as allowed under state law. If an adverse determination is overturned on appeal, and no other legal action related to the claim is pending, then the health carrier shall reimburse the health care provider at the contracted rate for inpatient care provided to the enrollee.
(3)This section does not require a health benefit plan to cover care, treatment, or services for a health condition that the terms of coverage otherwise completely exclude from the policy's covered benefits without regard for whether the care, treatment, or services are medically necessary.