§ 31-3875-09

09. Data transparency. (a)(1) Beginning January 1, 2025, a utilization review entity shall make available on its website, or by phone upon request, to an enrollee, representative, and health care provider, the information required by paragraph (2) of this subsection regarding the enrollee's active prior authorization requests made to that utilization review entity in at least the preceding 5 years; provided that, this paragraph shall not apply to a prior authorization request made before January 17, 2024. (2) The following information shall be made available to an enrollee: (A) A copy of all information or materials submitted by the enrollee's health care provider in support of a request for approval or reauthorization, or an appeal from an adverse determination, which shall clearly show the date the information or materials were submitted, the health care service prescribed by the health care provider, and the reason, if any, provided by the health care provider in requesting the health care service; and (B) A copy of all notices of determination provided to the enrollee issued pursuant to § 31-3875.03.

he reason, if any, provided by the health care provider in requesting the health care service; and (B) A copy of all notices of determination provided to the enrollee issued pursuant to § 31-3875.03. (b) Beginning January 1, 2025, a utilization review entity shall make publicly available on its website in a readily accessible format statistics regarding approvals, adverse determinations, and appeals, including information on the: (1) Specialties of physicians reviewing prior authorization requests or appeals; (2) Types of medication, tests, procedures, or treatment in which approval was being sought; (3) Medical indication offered in each request; (4) Reasons for an adverse determination; (5) Number of appeals taken; (6) Number of appeals approved or denied; (7) Time between submission of a request and the utilization review entity's determination; and (8) Time between submission of an appeal and the utilization review entity's determination. (c) For the purposes of this section, the term 'utilization review entity' shall not include an individual or entity that performs prior authorization review for a health benefits plan provided through Medicaid or the DC HealthCare Alliance.

term 'utilization review entity' shall not include an individual or entity that performs prior authorization review for a health benefits plan provided through Medicaid or the DC HealthCare Alliance. (Jan. 17, 2024, D.C. Law 25-100, § 109, 70 DCR 15238; Sept. 18, 2024, D.C. Law 25-217, § 5172(a), 71 DCR 9990.) Applicability Applicability of D.C. Law 25-100: § 301 of D.C. Law 25-100 provided that the creation of subsection (c) of this section by § 109 of D.C. Law 25-100 is subject to the inclusion of the law’s fiscal effect in an approved budget and financial plan. Therefore that amendment has not been implemented. Emergency Legislation For temporary (90 days) amendment of this section, see § 5172(a) of Fiscal Year 2025 Budget Support Emergency Act of 2024 (D.C. Act 25-506, July 15, 2024, 71 DCR 8406).