Draft H.31 would limit Vermont claim-edit rules for out-of-state care and define primary-care prior-authorization exemption

Summary

Legislative counsel walked lawmakers through H.31, which would clarify when Vermont claims-edit standards apply to care delivered outside the state and define which primary care providers are exempt from prior-authorization rules. Insurers told the committee they generally support the changes but urged a realistic implementation timeline.

A legislative committee received a walkthrough of H.31 on Jan. 17, a bill described by legislative counsel as “an act relating to claim edit standards and prior authorization requirements.”

The measure would add two clarifications: first, Vermontspecified claims-edit standards would not apply when a health care service was delivered outside Vermont unless the out-of-state provider and the payer agree those edits should apply. Second, the bill would define a primary care provider for the prior-authorization exemption as “a health care provider who is contracted and enrolled with the health plan as a primary care provider.”

Those two provisions matter because last yearin Act 111 (H.766)the Legislature set statewide expectations for how insurers process and edit claims and created a broad exemption from prior authorization for services ordered by primary care providers. Jen Karpy, Office of Legislative Counsel, told committee members the new language aims to resolve implementation questions that surfaced after the billnow enacted as Act…

Draft H.31 would limit Vermont claim-edit rules for out-of-state care and define primary-care prior-authorization exemption

Summary

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