Current through Reg. 50, No. 13; March 28, 2025
(a) Notice requirements. A URA must send
written notification to the enrollee or an individual acting on behalf of the
enrollee and the enrollee's provider of record, including the health care
provider who rendered the service, of a determination made in a utilization
review.
(b) Renewal of existing
preauthorizations. If a health benefit plan issuer subject to Insurance Code
Chapter 1222 requires preauthorization as a condition of payment for a medical
or health care service, the URA must provide a preauthorization renewal process
that allows a physician or health care provider to request renewal of an
existing preauthorization at least 60 days before the date the preauthorization
expires.
(c) Required notice
elements. In all instances of a prospective, concurrent, or retrospective
utilization review adverse determination, written notification of the adverse
determination by the URA must include:
(1) the
principal reasons for the adverse determination;
(2) the clinical basis for the adverse
determination;
(3) a description or
the source of the screening criteria that were utilized as guidelines in making
the determination;
(4) the
professional specialty of the physician, doctor, or other health care provider
that made the adverse determination;
(5) a description of the procedure for the
URA's complaint system as required by §
19.1705 of this title (relating to
General Standards of Utilization Review);
(6) a description of the URA's appeal
process, as required by §
19.1711 of this title (relating to
Written Procedures for Appeal of Adverse Determination);
(7) a copy of the request for a review by an
IRO form, available at www.tdi.texas.gov;
(8) notice of the independent review process
with instructions that:
(A) request for a
review by an IRO form must be completed by the enrollee, an individual acting
on behalf of the enrollee, or the enrollee's provider of record and be returned
to the insurance carrier or URA that made the adverse determination to begin
the independent review process; and
(B) the release of medical information to the
IRO, which is included as part of the independent review request for a review
by an IRO form, must be signed by the enrollee or the enrollee's legal
guardian; and
(9) a
description of the enrollee's right to an immediate review by an IRO and of the
procedures to obtain that review for an enrollee who has a life-threatening
condition or who is denied the provision of prescription drugs or intravenous
infusions for which the patient is receiving benefits under the health
insurance policy.
(d)
Determination concerning an acquired brain injury. In addition to the
notification required by this section, a URA must comply with this subsection
in regard to a determination concerning an acquired brain injury as defined by
§
21.3102 of this title (relating to
Definitions). Not later than three business days after the date an individual
requests utilization review or requests an extension of coverage based on
medical necessity or appropriateness, a URA must provide notification of the
determination through a direct telephone contact to the individual making the
request. This subsection does not apply to a determination made for coverage
under a small employer health benefit plan.
(e) Prospective and concurrent review.
(1) Favorable determinations. The written
notification of a favorable determination made in utilization review must be
mailed or electronically transmitted as required by Insurance Code §
4201.302.
(2) Preauthorization numbers. A URA must
ensure that preauthorization numbers assigned by the URA comply with the data
and format requirements contained in the standards adopted by the U.S.
Department of Health and Human Services in
45
C.F.R. §
162.1102, (relating to
Standards for Health Care Claims or Equivalent Encounter Information
Transaction), based on the type of service in the preauthorization
request.
(3) Required time frames.
Except as otherwise provided by the Insurance Code, the time frames for
notification of the adverse determination begin from the date of the request
and must comply with Insurance Code §
4201.304. A URA must
provide the notice to the provider of record or other health care provider not
later than one hour after the time of the request when denying
post-stabilization care subsequent to emergency treatment as requested by a
provider of record or other health care provider. The URA must send written
notification within three working days of the telephone or electronic
transmission.
(4) Required
timeframe for preauthorization renewal requests. A URA must review a request to
renew a preauthorization for a medical or health care service and make and
issue a determination before the existing preauthorization expires, if
practicable. The determination must indicate whether the medical or health care
service is preauthorized.
(f) Retrospective review.
(1) The URA must develop and implement
written procedures for providing the notice of adverse determination for
retrospective utilization review, including the time frames for the notice of
adverse determination, that comply with Insurance Code §
4201.305 and this
section.
(2) When a retrospective
review of the medical necessity, appropriateness, or the experimental or
investigational nature of the health care services is made in relation to
health coverage, the URA may not require the submission or review of a mental
health therapist's process or progress notes that relate to the mental health
therapist's treatment of an enrollee's mental or emotional condition or
disorder. This prohibition extends to requiring an oral, electronic, facsimile,
or written submission or rendition of a mental health therapist's process or
progress notes. This prohibition does not preclude requiring submission of:
(A) an enrollee's mental health medical
record summary; or
(B) medical
records or process or progress notes that relate to treatment of conditions or
disorders other than a mental or emotional condition or disorder.
