5465L.01I                                                                                                                                                  D. ADAM CRUMBLISS, Chief Clerk



To amend chapter 376, RSMo, by adding thereto one new section relating to prior authorization for insurance coverage of diagnostic radiology testing.

Be it enacted by the General Assembly of the state of Missouri, as follows:

            Section A. Chapter 376, RSMo, is amended by adding thereto one new section, to be known as section 376.408, to read as follows:

            376.408. 1. As used in this section, the following terms shall mean:

            (1) "Diagnostic radiology testing" includes the following diagnostic tests: X-ray, computerized tomography, magnetic resonance imaging, positron emission tomography, fluoroscopy, ultrasound, and nuclear imaging studies, including cardiac nuclear imaging;

            (2) "Health carrier", the same meaning as such term is defined in section 376.1350;

            (3) "Health benefit plan", the same meaning as such term is defined in section 376.1350;

            (4) "Radiology benefits manager", a person, business, or other entity, and any wholly or partially owned subsidiary of such entity, that administers diagnostic radiology and imaging benefits in any health benefit plan or policy of insurance that provides coverage for diagnostic radiology testing;

            (5) "Treating physician", a physician licensed under chapter 334 who orders or recommends to a patient a diagnostic radiology test that is based upon an in-person medical examination of the patient for whom the test is ordered or recommended.

            2. If a health carrier or health benefit plan provides coverage for diagnostic radiology testing and if a treating physician presents an order or recommendation for a diagnostic radiology test to a radiology benefits manager for authorization, a decision to deny authorization of the treating physician's order or recommendation shall only be made by a physician licensed in this state and subject to the regulation of the state board for the healing arts. Along with any decision to deny an authorization for diagnostic radiology testing, the treating physician and the patient shall be furnished with the full name, mailing address, telephone number, and employer of the radiology benefits manager physician who is making the denial decision. In every case in which authorization to perform a diagnostic radiology test is given by a health carrier or health benefit plan or by a radiology benefits manager which is contracted to provide utilization review services for the health carrier or health benefit plan, such authorization shall be conclusive to satisfy any requirement of medical necessity in a health benefit plan or a health carrier's plan, policy, or schedule of benefits, and the provider's subsequently filed claim for payment for such services shall not be denied but shall be timely paid, unless there was fraud on the part of the provider in procuring the authorization.

            3. Electronic clinical decision support tools which offer ordering guidance to physicians and can document the clinical appropriateness of the order are not subject to the provisions of this section.