Date Requested: January 23, 2018
Time Requested: 04:44 PM
Agency: Public Employees Insurance Agency (PEIA)
CBD Number: Version: Bill Number: Resolution Number:
1942 Introduced HB4239
CBD Subject: Insurance



Sources of Revenue:

Special Fund

Legislation creates:

Fiscal Note Summary

Effect this measure will have on costs and revenues of state government.

    The purpose of this bill is to establish universal forms and establish deadlines when a prior authorization is submitted electronically.
    PEIA utilizes a third-party administrator (TPA) to administer prior authorizations. PEIA has requested this functionality be in compliance with this bill which may increase overall TPA costs due to the development of the system. These development costs by the TPA will be incorporated into their charges to PEIA. The amount of these costs is currently unknown and difficult to estimate at this point in the development process.
    There is potential for other administrative cost increases to PEIA due to other requirements set forth in this bill. In the event another standard is purchased and adopted by the TPA, the requirement for MCG (formerly known as Milliman) utilization in West Virginia would cause additional costs as the TPA will be required to own and administer multiple standards to service PEIA. These criteria software applications cost approximately $200,000 per year.
    The requirement to utilize Milliman/MCG criteria is also a concern as it is not all inclusive and other standards are necessary at times due to the specifics of the request. It is recommended the bill be revised to allow for an approved and appropriate standard per the specifics of the request.
    The current TPA is URAC compliant. Currently, all requests deemed urgent care services as defined by URAC standards are responded to within 24 hours. There is potential for conflict with URAC standards regarding the definition of urgent care services. There are also differences with some of the bills timeframe requirements as compared to other State Law, NCQA, Medicare and DOL requirements. A possible revision to require utilization of an acceptable accrediting agency, or applicable State or Federal law might be considered. The determination of which to follow would be dependent on the location of delivery of the service, the type of service or patient type.
    If this bill will include prior authorizations for services rendered outside of West Virginia, there is potential for cost increases in the event the review is processed by the out of state network administrator. The cause would be similar to those outlined above for the in-state prior authorizations.

Fiscal Note Detail

Effect of Proposal Fiscal Year
Fiscal Year
(Upon Full
1. Estmated Total Cost 0 0 0
Personal Services 0 0 0
Current Expenses 0 0 0
Repairs and Alterations 0 0 0
Assets 0 0 0
Other 0 0 0
2. Estimated Total Revenues 0 0 0

Explanation of above estimates (including long-range effect):

    Please explain increases and decreases in personal services, current expenses, repairs and alterations, assets, other costs and revenues, including assumptions and data sources and delineation between start-up and ongoing costs. Please also include a long-range schedule of costs and revenues if fiscal impact is expected to vary in future years.


    The amount of these costs is currently unknown and difficult to estimate at this point in the development process.

    Person submitting Fiscal Note: Jason Haught
    Email Address: