Committee approves H.31 to clarify out-of-state claim edits and who qualifies as a primary care provider for prior-authorization exemptions

The Vermont House Committee on Health Care approved H.31 on Jan. 29 to clarify when health insurance claim edit standards apply and to revise the definition of “primary care provider” for prior-authorization exemptions.

Jen Carvey, Office of Legislative Counsel, told the committee the bill makes two main changes: it specifies that otherwise applicable claim edit standards do not apply when services are delivered outside Vermont unless the payer and the out-of-state provider agree otherwise, and it revises the prior-authorization exemption so that a “primary care provider” means a health care provider contracted and enrolled with the health plan as a primary care provider.

The clarification matters because, Carvey said, Vermont generally lacks authority to regulate activities that occur entirely outside the state: “We typically do not try to regulate what happens outside of the borders of Vermont. We generally don't have the authority to do that,” she said. The bill allows payers and out-of-state providers to contractually agree that some standards will apply.

On the prior-authorization definition, Carvey said the revised language…