SB45,1448,19 (d) “Health care provider” has the meaning given in s. 146.81 (1) (a) to (p).

SB45,1448,23 (e) “Prior authorization” means a determination by a health benefit plan, self- insured health plans, or person contracting with a health benefit plan or self- insured health plan that health care items or services proposed to be provided to a patient are medically necessary and appropriate.

SB45,1448,24 (f) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c).

SB45,1449,8 (2) The commissioner may by rule provide that any health benefit plan or self- insured health plan that uses a prior authorization process shall exempt health care providers from obtaining prior authorizations for a health care item or service for a period of time established by the commissioner if, in the most recent evaluation period, the health benefit plan or self-insured health plan has approved or would have approved not less than the proportion of prior authorization requests established under sub. (3) submitted by the health care provider for the health care item or service.

SB45,1449,12 (3) The commissioner shall specify the proportion of prior authorization requests submitted by a health care provider that have to be approved for the health care provider to qualify for an exemption from obtaining prior authorizations under sub. (2).

SB45,1449,15 (4) The commissioner may specify by rule the health care items or services that may be subject to the exemption from obtaining prior authorizations under sub. (2).

SB45,1449,18 (5) The commissioner may specify how health care providers may obtain an exemption from obtaining prior authorizations under sub. (2) including by providing a process for automatic evaluation.

SB45,1449,20 (6) The commissioner may promulgate further rules necessary to implement this section.

SB45,2942 Section 2942. 632.851 of the statutes is created to read:

SB45,1449,23 632.851 Reimbursement of emergency ambulance services. (1) In this section:

SB45,1449,24 (a) “Ambulance service provider” has the meaning given in s. 256.01 (3).

SB45,1450,4 (b) “Clean claim” means a claim that has no defect of impropriety, including a lack of required substantiating documentation or any particular circumstance that requires special treatment that prevents timely payment from being made on the claim.

SB45,1450,5 (c) “Emergency medical responder” has the meaning given in s. 256.01 (4p).

SB45,1450,7 (d) “Emergency medical services practitioner” has the meaning given in s. 256.01 (5).

SB45,1450,8 (e) “Firefighter” has the meaning given in s. 36.27 (3m) (a) 1m.

SB45,1450,9 (f) “Health care provider” has the meaning given in s. 146.81 (1) (a) to (hp).

SB45,1450,10 (g) “Law enforcement officer” has the meaning given in s. 165.85 (2) (c).

SB45,1450,11 (h) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c).

SB45,1450,17 (2) (a) A disability insurance policy or self-insured health plan shall, within 30 days after receipt of a clean claim for covered emergency ambulance services, promptly remit payment for the covered emergency ambulance services directly to the ambulance service provider. No disability insurance policy or self-insured health plan may send a payment for covered emergency ambulance services to an enrollee.

SB45,1450,22 (b) A disability insurance policy or self-insured health plan shall respond to a claim for covered emergency ambulance services that is not a clean claim by sending a written notice, within 30 days after receipt of the claim, acknowledging the date of receipt of the claim and informing the ambulance service provider of one of the following:

SB45,1451,2 1. That the disability insurance policy or self-insured health plan is declining to pay all or part of the claim, including the specific reason or reasons for the denial.

SB45,1451,4 2. That additional information is necessary to determine if all or part of the claim is payable and the specific additional information that is required.

SB45,1451,9 (3) A disability insurance policy or self-insured health plan shall remit payment for the transportation of any patient by ambulance as a medically necessary emergency ambulance service if the transportation was requested by an emergency medical services practitioner, an emergency medical responder, a firefighter, a law enforcement officer, or a health care provider.

SB45,2943 Section 2943. 632.862 of the statutes is created to read:

SB45,1451,12 632.862 Application of prescription drug payments. (1) Definitions. In this section:

SB45,1451,13 (a) “Brand name” has the meaning given in s. 450.12 (1) (a).

SB45,1451,14 (b) “Brand name drug” means any of the following:

SB45,1451,16 1. A prescription drug that contains a brand name and that has no generic equivalent.

SB45,1451,21 2. A prescription drug that contains a brand name and has a generic equivalent but for which the enrollee has received prior authorization from the insurer offering the disability insurance policy or self-insured health plan or authorization from a physician to obtain the prescription drug under the disability insurance policy or self-insured health plan.