Part I.

Adds the following terms to the definitions governing utilization reviews (GS 58-50-61): chronic or long-term condition, closely related service, course of treatment, prior authorization, and urgent healthcare service. Modifies the definitions of the terms clinical peer, emergency services, participating provider, stabilize, and utilization review (UR).

Sets forth the five following clinical criteria that every insurer’s or utilization review organization (URO)’s UR program must meet:

1. The criteria used is based on applicable nationally recognized medical standards.
2. The clinical review and standards used are consistent with applicable government guidelines.
3. The clinical review provides for the delivery of a healthcare service in a clinically appropriate type, frequency, and setting and for a clinically appropriate duration.
4. The criteria used in the clinical review reflects the current medical and scientific evidence regarding emerging procedures, clinical guidelines, and best practices, as articulated in independent, peer-reviewed medical literature.
5. The clinical review is sufficiently flexible to allow deviations from the norm when justified on a case-by-case basis to ensure access to care.

Prevents an insurer or URO from developing its own criteria governing when a patient needs to be placed in a substance abuse treatment program. Now requires that a noncertification (i.e., a denial of insurance coverage) are to be made by a medical doctor who, in addition to the licensure requirements described, is of the same specialty as the provider managing the patient’s condition underlying the request for services and who has experience treating patients with that condition. Requires physicians to issue noncertifications under the clinical direction of the insurer’s medical directors as described.  Extends the statute’s obligations in issuing a UR to URO’s (currently, just insurers). Provides for notice if the insurer or its URO is questioning the medical necessity of the healthcare service under review along with opportunity for consultation with the insured’s healthcare provider.  Requires insurers to maintain a public list of services for which a UR is required, including those provided by a third party contractor, and ensure that its UR does the same.

Modifies the timeline for completion of a prospective or current UR, including requiring a 24-hour turnaround as described for urgent healthcare services and requiring coverage of emergency services to screen and stabilize an insured. (Currently, UR timeline is three business days after insurer receives the described information.) Also sets out timelines governing non-urgent healthcare services and emergency services. Provides a timeline governing instances when the insurer or URO requires additional information.   

Extends the statute’s obligations governing retrospective UR’s to URO’s. Modifies the notice requirements for noncertifications in these instances. Subject to the provisions governing UR statistics, prevents an insurer from revoking, limit, condition, or restrict a UR if care that has been previously certified by the insurer or its URO is provided within 45 business days from the date the provider received the UR. Requires an insurer to pay a provider unless any of the six specified conditions apply, including that the provider failed to meet the insurer's timely filing requirements and that the covered person was no longer eligible for healthcare on the day the care was provided.

Modifies the requirements for notice of noncertification so that the information has to include the name and medical specialty of all medical doctors involved in the noncertification. Instructs that if an insurer or URO failing to approve, deny, or request additional information for a requested UR within the applicable time frames is deemed to have approved the request. Requires that a medical doctor review appeals as specified. Extends obligations governing non-expedited appeals and expedited appeals to UROs. Requires disclosure of UR processes in detail and easily understandable language in the listed documents, now including the insurer’s website. Sets forth notice requirements that apply when an insurer intends to implement a new UR requirement or restriction or if it amends its current requirements/restrictions. Specifies that the notice provisions do not apply if an insurer removes a UR requirement or restriction or amends a restriction or requirement to be less restrictive. Requires disclosure of the specified UR statistics as described on the insurer’s website.

Directs that UR is valid for the entire duration of the approved course of treatment and effective regardless of any changes in dosage for a prescription drug prescribed by a provider. Specifies that if an insurer requires a UR for a healthcare service for the treatment of a chronic or long-term care condition, then the UR is valid for the length of the treatment and the insurer may not require the covered person to obtain a UR determination again for the healthcare service. Sets forth five provisions applicable to continuity of care.

Except for URs that pending review by an insurer or URO, prevents an insurer from requiring a to request a UR  for a healthcare service in order for the covered person to whom the healthcare service is being provided to receive coverage for the service if, within the most recent 12-month period, the insurer or its URO has issued certifications, or would have issued certifications, for not less than 80% of the UR’s submitted by the provider  for that healthcare service. Permits an insurer to evaluate whether the provider continues to qualify for the exemption once every 12 months. Specifies six conditions that apply to the exemption, including conditions under which the insurer may revoke the exemption and a healthcare provider’s right of appeal to an insurer’s denial of an exemption. Clarifies that the exemption does not require an insurer to evaluate an existing exemption or prevent an insurer from establishing a longer exemption period.

Directs that any failure by an insurer or URO to comply with the deadlines and other requirements in GS 58-50-61 results in any healthcare service subject to review to be automatically deemed authorized by the insurer.

Makes technical, organizational, conforming, and clarifying changes.

Enacts GS 58-3-500, requiring insurers offering health benefits to provide the six prongs of required information pertaining to UR’s to the Insurance Commissioner (Commissioner) by March 1 each year. Authorizes the Commissioner to adopt rules, including requiring additional information pertaining to UR’s. Requires the Commissioner to submit an annual report to the specified NCGA committee by April 1 each year. Provides for a $5,000 daily fine for each day an insurer fails to provide the information required under GS 58-3-500.

Applies to insurance contracts issued, renewed, or amended on or after October 1, 2025.

Directs the State Treasurer and the Executive Administrator of the State Health Plan to review all practices of the State Health Plan and all contracts with, and practices of, any third party conducting any utilization review on behalf of the State Health Plan to ensure compliance with GS 58-50-61, as amended by the act. 

Part II.

Extends the definition of practicing medicine or surgery under GS 90-1.1 (definitions pertaining to the practice of medicine) to include performing any part of a UR governed by GS 58-50-61. Enacts GS 58-50-64 (UR disciplinary actions) giving the NC Medical Board (Board) authority to subpoena an insurer, or a URO acting on behalf of an insurer, for any records, documents, or other materials pertaining to the involvement of any physician licensed in this State in a UR governed by GS 58-50-61. Subjects nonresponsive insurers and URO’s to a fine of not less than $500 or each 90-day period in which the subpoenaed information is withheld. Specifies that if the Board disciplines a reviewing physician than any of the noncertifications issued that related, in whole or in part, to the disciplinary action is subject to reconsideration or appeal so long as the noncertification had not been reversed prior to the disciplinary action. Requires the Board to notify the insurer of the disciplinary action and UR involved. Makes conforming changes to GS 135-48.10 (confidentiality of information and medical information under the State Health Plan) to account for the expanded scope of the practice of medicine, the Board’s subpoena power, and its notice requirements.

Part III.

Incorporates the definitions of GS 58-50-61 to GS 58-50-62 (insurer grievance procedures). Repeals definition of health benefit plan under GS 58-50-61(a)(7).  Removes defined term covered person and makes conforming and technical changes to GS 58-50-75 (purpose, scope, and definitions governing external reviews of health benefit plans). Makes conforming change to GS 90-21.52.