Living dossier · 10 linked objects · state as of
Prior authorization
A prior authorisation is valid for a period the payer sets, and an adverse determination can be produced by an automated system without a named clinician who owns it. California AB 539 would impose a twelve-month duration floor; it completed legislative passage on 31 August 2026 and is not law. Federal interoperability rules set decision timelines for certain plans but reach neither duration nor automation.
What the law provides
California law sets response timeframes and requires that denials on medical necessity be made by a licensed reviewer with appropriate expertise. Federal rules impose decision timelines on certain Medicare Advantage and marketplace plans. Neither fixes authorisation duration, neither guarantees continuity across a plan transition, and neither bars an automated final denial.
The gap
Three things are unaddressed: how long an approval lasts, what happens to a stable therapy when coverage changes, and who is accountable when software generates the denial.
The KPSGILL position
Authorisation valid for the course of treatment or twelve months; ninety-day continuity on coverage transition; a named accountable clinician on every adverse determination; disclosure of automated involvement. Preferred sequencing publishes plan-level overturn rates first, because the published data is what makes the rest enforceable.
The open question
If automation may recommend a denial but a named clinician must own it, what stops the naming from becoming a formality — a single reviewer attesting to thousands of machine determinations?
Litigation
A feasibility analysis rather than a docket: which theories could test an automated denial, and where each one runs into ERISA preemption or the absence of a duty running to the patient.
Tracked legislation
| Bill | Subject | State |
|---|---|---|
| AB 539 | Prior authorization: duration of approval | LEGISLATIVE PASSAGE COMPLETE |
Everything KPSGILL has published on this
Derived from the topic entity in the entity registry. A page tagged to this topic appears here without this dossier being edited.
- Claim Denials and the Appeals Ladder
- Algorithmic Prior Authorization and Human Accountability
- Electronic Prior Authorization: What CMS-0057-F Actually Obliges, and What It Leaves Alone
- Step Therapy and Exception Rights
- Investigating Prior Authorization Delays
- Public Reporting of Prior-Authorization Metrics
- Peer-to-Peer Review in Prior Authorization: Clinical Conversation, Coverage Process, and the Limits of Informal Reconsideration
- Prior Authorization: What It Is, Why It Can Delay Care, and What You Can Do
How progress would be measured
- Adverse determinations per thousand covered lives
- Overturn rate on internal appeal, by plan
- Therapy interruptions at coverage transition
- Median days from request to determination
Entity topic.prior-authorization · all dossiers · event timeline · methodology