Ohio establishes streamlined appeal process for prior authorization determinations

On April 1, 2025, the Ohio Legislature introduced House Bill 220, aimed at reforming the prior authorization process for healthcare services, drugs, and devices. The bill seeks to address ongoing concerns regarding delays in patient care and the administrative burdens placed on healthcare providers.

One of the bill's key provisions is the establishment of a streamlined appeal process for adverse prior authorization determinations. Under this proposal, urgent care service appeals must be resolved within 48 hours, while all other appeals are to be addressed within ten calendar days. This expedited timeline is designed to ensure timely access to necessary medical services, particularly for urgent cases.

Additionally, the bill mandates that appeals be conducted between the healthcare provider and a clinical peer appointed by the department or its designee. This peer must possess relevant qualifications, and the decision-making process will be transparent, as the provider will receive information about the peer's credentials. Importantly, the bill prohibits the imposition of fees for appealing adverse determinations, aiming to reduce financial barriers for patients and providers alike.

Another significant aspect of House Bill 220 is the protection against retroactive denials of prior authorizations, effective from January 1, 2017. This provision stipulates that, barring instances of fraud or materially incorrect information, prior authorizations cannot be revoked after they have been granted, which is particularly relevant for mental health and substance use disorder treatments.

The introduction of House Bill 220 has sparked discussions among lawmakers and stakeholders. Proponents argue that the bill will enhance patient care by reducing delays and administrative hurdles, while critics express concerns about the potential for increased costs to the healthcare system. The bill's implications could be far-reaching, potentially impacting healthcare access and the operational dynamics of healthcare providers across Ohio.

As the legislative process unfolds, experts anticipate that further debates and amendments may arise, particularly regarding the balance between regulatory oversight and the need for efficient healthcare delivery. The bill's progress will be closely monitored, as its outcomes could set a precedent for similar reforms in other states.