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Please see http://docs.legis.wisconsin.gov for the production version.
Generally, this bill requires and prohibits certain actions related to prior
authorization of physical therapy and other health care services by certain health
plans. Under the bill, every health plan, when requested to reauthorize coverage,
must issue a decision on reauthorization of coverage of a service for which prior
authorization was previously obtained within 48 hours or prior authorization is
assumed to be granted. Health plans are prohibited under the bill from requiring
prior authorization for the first 12 physical therapy visits with no duration of care
limitation or for any nonpharmacologic management of pain provided through care
related to physical therapy provided to individuals with chronic pain for the first 90
days of treatment. The bill requires plans to reference the applicable policy and
include an explanation to the physical therapy service provider and to the covered
individual for an denial of coverage for or reduction in covered physical therapy
services and to compensate physical therapy service providers as specified under the
bill for data entry of clinical information that is required by a utilization review
organization or utilization management organization acting on behalf of a plan. A
plan must also impose copayment and coinsurance amount on covered individuals
for physical therapy services that are equivalent to copayment and coinsurance
amounts imposed for primary care services under the plan.

The bill also requires every utilization review organization and utilization
management organization that is providing review or management on behalf of a
health plan to provide to any licensed health care provider, upon request, all medical
evidence-based policy information that accompanies the algorithms that are used
to manage coverage and to operate and staff peer review activities with
Wisconsin-licensed health care providers holding credentials for the type of service
that is the subject of the review. The bill prohibits utilization review organizations
and utilization management organizations from using claims data as evidence of
outcomes for purposes developing an algorithm to manage coverage or an approval
policy for coverage. Health plans to which the above requirements and prohibitions
apply are private health benefit plans and self-insured governmental health plans.
Additionally, the bill prohibits health care plans and self-insured
governmental health plans from requiring prior authorization for coverage of any
covered health care service that is incidental to a primary covered health care service
and determined by the covered person's physician or other health care provider to be
medically necessary and of any covered urgent health care service as defined in the
bill. Current law prohibits health care plans and self-insured governmental health
plans from requiring prior authorization for coverage of emergency medical services.
This proposal may contain a health insurance mandate requiring a social and
financial impact report under s. 601.423, stats.
The people of the state of Wisconsin, represented in senate and assembly, do
enact as follows:
SB972,1 1Section 1. 632.85 (title) of the statutes is amended to read:
SB972,2,3 2632.85 (title) Coverage without prior authorization for treatment of an
3emergency medical condition
; other conditions.
SB972,2 4Section 2. 632.85 (1) (d) of the statutes is created to read:
SB972,2,85 632.85 (1) (d) “Urgent health care service” means a health care service for
6which the application of the time for making a nonexpedited request for prior
7authorization, in the opinion of a physician or other health care provider with
8knowledge of the covered person's medical condition, could do any of the following:
SB972,2,109 1. Seriously jeopardize the life or health of the covered person or the ability of
10that person to regain maximum function.
SB972,3,2
12. Subject the covered person to severe pain that cannot be adequately
2managed without the care or treatment that is the subject of the utilization review.
SB972,3 3Section 3. 632.85 (3) of the statutes is amended to read:
SB972,3,104 632.85 (3) A health care plan or a self-insured health plan that is required to
5provide the coverage under sub. (2) may not require prior authorization for the
6provision or coverage of the emergency medical services specified in sub. (2), any
7covered health care service that is incidental to a primary covered health care service
8and determined by the covered person's physician or other health care provider to be
9medically necessary, or any covered health care service that is an urgent health care
10service
.
SB972,4 11Section 4. 632.851 of the statutes is created to read:
SB972,3,13 12632.851 Prior authorization; general; physical therapy. (1) In this
13section:
SB972,3,1414 (a) “Health benefit plan” has the meaning given in s. 632.745 (11).
SB972,3,1615 (b) “Self-insured health plan” means a self-insured health plan of the state or
16a county, city, village, town, or school district.
SB972,3,18 17(2) A health benefit plan or self-insured health plan that uses prior
18authorization procedures may not do any of the following:
SB972,3,2119 (a) Require prior authorization for the first 12 physical therapy visits with no
20duration of care limitation. A plan may require prior authorization for visits after
21the initial 12 physical therapy visits of an episode of care for a specific condition.
SB972,3,2422 (b) Require prior authorization for any nonpharmacologic management of pain
23provided through care related to physical therapy provided to individuals with
24chronic pain for the first 90 days of treatment.
SB972,4,3
1(3) A health benefit plan or self-insured health plan that provides coverage of
2physical therapy services shall do all of the following with respect to physical therapy
3services:
SB972,4,64 (a) Reference the applicable policy and include an explanation to the physical
5therapy service provider and, in plain language, to the covered individual for any
6denial of coverage or reduction in covered services.
SB972,4,167 (b) Compensate providers of physical therapy services at 50 percent of the
8current procedure terminology code rate for a therapeutic physical therapy
9procedure on one or more areas each lasting 15 minutes for each quarter hour of data
10entry of clinical information that is required by a utilization review organization or
11utilization management organization acting on behalf of a plan. The physical
12therapy service provider shall invoice the utilization review organization or
13utilization management organization monthly to obtain the compensation described
14under this paragraph or the health benefit plan or self-insured health plan shall
15increase reimbursement to physical therapy service providers commensurate with
16increased administrative expenses.
SB972,4,1917 (c) Impose copayment and coinsurance amounts on covered individuals for
18physical therapy services that are equivalent to copayment and coinsurance
19amounts imposed on covered individuals for primary care services under the plan.
SB972,4,24 20(4) Every health benefit plan or self-insured health plan when requested to
21reauthorize coverage of a service for which prior authorization was previously
22obtained shall issue the decision on reauthorization within 48 hours of the request.
23If a plan does not issue a decision on reauthorization described under this subsection
24within 48 hours, prior authorization is assumed to be granted for the service.
SB972,5,3
1(5) Every utilization review organization and utilization management
2organization that is providing review or management on behalf health benefit plan
3or self-insured health plan shall do all of the following:
SB972,5,84 (a) Provide to any licensed health care provider upon request all medical
5evidence-based policy information that accompanies the algorithms that are used
6to manage coverage. A utilization review organization or utilization management
7organization may not use claims data as evidence of outcomes for purposes
8developing an algorithm to manage coverage or an approval policy for coverage.
SB972,5,119 (b) Operate and staff peer review activities with health care providers that are
10licensed in this state and hold credentials for the type of service that is the subject
11of the review.
SB972,5,1212 (End)
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