[§323D-19.1]  Health care appropriateness and necessity working group; established.  (a)  There is established the health care appropriateness and necessity working group within the state agency.  The working group shall:

     (1)  Determine by research and consensus:

          (A)  The most respected peer-reviewed national scientific standards;

          (B)  Clinical guidelines; and

          (C)  Appropriate use criteria published by federal agencies, academic institutions, and professional societies,

          that correspond to each of the most frequent clinical treatments, procedures, medications, diagnostic images, laboratory and diagnostic tests, or types of medical equipment prescribed by licensed physicians and other health care providers in the State that trigger prior authorization determinations by the utilization review entities;

     (2)  Assess whether it is appropriate to require prior authorization for each considered clinical treatment, procedure, medication, diagnostic image, laboratory and diagnostic test, or type of medical equipment prescribed by licensed physicians and other health care providers;

     (3)  Make recommendations on standards for third party reviewers related to the specialty expertise of those reviewing and for those discussing a patient's denial with the patient's health care provider;

     (4)  Recommend appropriate time frames within which urgent and standard requests shall be decided;

     (5)  Monitor anticipated federal developments related to prior authorization for health care services and consider these developments when making its recommendations;

     (6)  Assess industry progress toward, and readiness to implement, any recommendations; and

     (7)  Make recommendations on treatments for common chronic or long-term conditions for which prior authorization may remain valid for the duration of the treatment in the appropriate clinical setting.

     (b)  The administrator of the state agency shall invite the following to be members of the working group:

     (1)  Five members representing the insurance industry, to be selected by the Hawaii Association of Health Plans;

     (2)  Five members representing licensed health care professionals, two of whom shall be selected by the Hawaii Medical Association, two of whom shall be selected by the Healthcare Association of Hawaii, and one of whom shall be selected by the center for nursing; and

     (3)  Five members representing consumers of health care or employers, two of whom shall be selected by the board of trustees of the Hawaii employer-union health benefits trust fund, one of whom shall be a consumer selected by the statewide health coordinating council, one of whom shall be selected by the Hawaii Primary Care Association, and one of whom shall be selected by Papa Ola Lokahi.

     The members of the working group shall elect a chairperson and vice chairperson from amongst themselves.  The director of health, insurance commissioner, and administrator of the med-QUEST division of the department of human services shall each appoint an ex-officio advisor for the working group.

     (c)  The working group shall submit a report of its findings and recommendations regarding information under subsection (a), including any proposed legislation, to the legislature no later than twenty days prior to the convening of the regular session of 2026 and each regular session thereafter.

     (d)  The recommendations of the working group shall be advisory only and not mandatory for health care facilities, health care professionals, insurers, and utilization review entities.  The state agency shall promote the recommendations among health care facilities, health care professionals, insurers, and utilization review entities and shall publish annually in its report to the legislature the extent and impacts of its use in the State.

     (e)  The state agency shall seek transparency and agreement among health care facilities, health care professionals, insurers, utilization review entities, and consumers related to the most respected clinical, scientific, and efficacious standards, guidelines, and appropriate use criteria corresponding to medical treatments and services most commonly triggering prior authorization determinations to reduce uncertainty around common prior authorization processes, and also foster automation of prior authorization to the benefit of all.  The state agency shall explore means of achieving statewide health sector agreement on means of automating prior authorization determinations that decrease delays and disruptions of medically necessary patient care in the near future. [L 2025, c 151, pt of §2]