Current through Reg. 50, No. 13; March 28, 2025
(a) The words and
terms defined in Insurance Code Chapter 1301 and Chapter 843 have the same
meaning when used in this section, except as otherwise provided by this
subchapter, unless the context clearly indicates otherwise.
(b) An HMO or preferred provider benefit plan
that requires preauthorization as a condition of payment to a preferred
provider must comply with the procedures of this section for determinations of
medical necessity, appropriateness, or the experimental or investigational
nature of care for those services the HMO or preferred provider benefit plan
identifies under subsection (c) of this section.
(c) An HMO or preferred provider benefit plan
that uses a preauthorization process for medical care or health care services
must provide to each contracted preferred provider, not later than the fifth
working day after the date a request is made, a list of medical care and health
care services that allows a preferred provider to determine which services
require preauthorization and information concerning the preauthorization
process.
(d) An HMO or preferred
provider benefit plan must issue and transmit a determination indicating
whether the proposed medical or health care services are preauthorized. This
determination must be issued and transmitted once a preauthorization request
for proposed services that require preauthorization is received from a
preferred provider. The HMO or preferred provider benefit plan must respond to
a request for preauthorization within the following time periods:
(1) For services not included under
paragraphs (2) and (3) of this subsection, a determination must be issued and
transmitted not later than the third calendar day after the date the request is
received by the HMO or preferred provider benefit plan. If the request is
received outside of the period requiring the availability of appropriate
personnel as required in subsections (e) and (f) of this section, the
determination must be issued and transmitted within three calendar days from
the beginning of the next time period requiring appropriate
personnel.
(2) If the proposed
medical or health care services are for concurrent hospitalization care, the
HMO or preferred provider benefit plan must issue and transmit a determination
indicating whether proposed services are preauthorized within 24 hours of
receipt of the request, followed within three working days after the
transmittal of the determination by a letter notifying the enrollee or the
individual acting on behalf of the enrollee and the provider of record of an
adverse determination. If the request for medical or health care services for
concurrent hospitalization care is received outside of the period requiring the
availability of appropriate personnel as required in subsections (e) and (f) of
this section, the determination must be issued and transmitted within 24 hours
from the beginning of the next time period requiring appropriate
personnel.
(3) If the proposed
medical care or health care services involve post-stabilization treatment, or a
life-threatening condition as defined in §
19.1703 of this title (relating to
Definitions), the HMO or preferred provider benefit plan must issue and
transmit a determination indicating whether proposed services are preauthorized
within the time appropriate to the circumstances relating to the delivery of
the services and the condition of the enrollee, but in no case to exceed one
hour from receipt of the request. If the request is received outside of the
period requiring the availability of appropriate personnel as required in
subsections (e) and (f) of this section, the determination must be issued and
transmitted within one hour from the beginning of the next time period
requiring appropriate personnel. The determination must be provided to the
provider of record. If the HMO or preferred provider benefit plan issues an
adverse determination in response to a request for post-stabilization treatment
or a request for treatment involving a life-threatening condition, the HMO or
preferred provider benefit plan must provide to the enrollee or individual
acting on behalf of the enrollee, and the enrollee's provider of record, the
notification required by §
19.1717(a) and
(b) of this title (relating to Independent
Review of Adverse Determinations).
(e) A preferred provider may request a
preauthorization determination via telephone from the HMO or preferred provider
benefit plan. An HMO or preferred provider benefit plan must have appropriate
personnel as described in §
19.1706 of this title (relating to
Requirements and Prohibitions Relating to Personnel) reasonably available at a
toll-free telephone number to provide the determination between 6:00 a.m. and
6:00 p.m., Central Time, Monday through Friday on each day that is not a legal
holiday and between 9:00 a.m. and noon, Central Time, on Saturday, Sunday, and
legal holidays. An HMO or preferred provider benefit plan must have a telephone
system capable of accepting or recording incoming requests after 6:00 p.m.,
Central Time, Monday through Friday and after noon, Central Time, on Saturday,
Sunday, and legal holidays and must acknowledge each of those calls not later
than 24 hours after the call is received. An HMO or preferred provider benefit
plan providing a preauthorization determination under subsection (d) of this
section must, within three calendar days of receipt of the request, provide a
written notification to the preferred provider.
(f) An HMO providing routine vision services
or dental health care services as a single health care service plan is not
required to comply with subsection (e) of this section with respect to those
services. An HMO providing routine vision services or dental health care
services as a single health care service plan must:
(1) have appropriate personnel as described
in §
19.1706 of this title reasonably
available at a toll-free telephone number to provide the preauthorization
determination between 8:00 a.m. and 5:00 p.m., Central Time, Monday through
Friday on each day that is not a legal holiday;
(2) have a telephone system capable of
accepting or recording incoming requests after 5:00 p.m., Central Time, Monday
through Friday and all day on Saturday, Sunday, and legal holidays, and must
acknowledge each of those calls not later than the next working day after the
call is received; and
(3) when
providing a preauthorization determination under subsection (d) of this
section, within three calendar days of receipt of the request, provide a
written notification to the preferred provider.
(g) If an HMO or preferred provider benefit
plan has preauthorized medical care or health care services, the HMO or
preferred provider benefit plan may not deny or reduce payment to the physician
or provider for those services based on medical necessity, appropriateness, or
the experimental or investigational nature of care unless the physician or
provider has materially misrepresented the proposed medical or health care
services or has substantially failed to perform the preauthorized medical or
health care services.
(h) If an HMO
or preferred provider benefit plan issues an adverse determination in response
to a request made under subsection (d) of this section, a notice consistent
with the provisions of §
19.1709 of this title (relating to
Notice of Determinations Made in Utilization Review) and §
19.1710 of this title (relating to
Requirements Prior to Issuing Adverse Determination) must be provided to the
enrollee or an individual acting on behalf of the enrollee, and the enrollee's
provider of record. An enrollee, an individual acting on behalf of the
enrollee, or the enrollee's provider of record may appeal any adverse
determination under §
19.1711 of this title (relating to
Written Procedures for Appeal of Adverse Determination).
(i) This section applies to an agent or other
person with whom an HMO or preferred provider benefit plan contracts to perform
utilization review, or to whom the HMO or preferred provider benefit plan
delegates the performance of preauthorization of proposed medical or health
care services. Delegation of preauthorization services does not limit in any
way the HMO or preferred provider benefit plan's responsibility to comply with
all statutory and regulatory requirements.
(j) The provisions in this subsection apply
to an HMO or a preferred provider benefit plan that uses a preauthorization
process for medical or health care services.
(1) An HMO or a preferred provider benefit
plan must make the requirements and information about the preauthorization
process readily accessible to enrollees, physicians, health care providers, and
the general public by posting the requirements and information on the HMO's or
the preferred provider benefit plan's public internet website.
(2) The preauthorization requirements and
information described by paragraph (1) of this section must:
(A) be posted:
(i) conspicuously in a location on the public
internet website that does not require the user to login or input personal
information to view the information; except as provided by paragraph (3) or (4)
of this subsection;
(ii) in a
format that is easily searchable; and
(iii) in a format that uses design and
accessibility standards defined in Section 508 of the U.S. Rehabilitation
Act;
(B) except for the
screening criteria under subparagraph (D)(iii) of this paragraph, be written:
(i) using plain language standards, such as
the Federal Plain Language Guidelines found on www.PlainLanguage.gov;
and
(ii) in language that aims to
reach a 6th to 8th grade reading level, if the information is for enrollees and
the public;
(C) include a
detailed description of the preauthorization process and procedure;
and
(D) include an accurate and
current list of medical or health care services for which the HMO or the
preferred provider benefit plan requires preauthorization that includes the
following information specific to each service:
(i) the effective date of the
preauthorization requirement;
(ii)
a list or description of any supporting documentation that the HMO or preferred
provider benefit plan requires from the physician or health care provider
ordering or requesting the service to approve a request for that
service;
(iii) the applicable
screening criteria, which may include Current Procedural Terminology codes and
International Classification of Diseases codes; and
(iv) statistics regarding the HMO's or the
preferred provider benefit plan's preauthorization approval and denial rates
for the service in the preceding calendar year, including statistics in the
following categories:
(I) physician or health
care provider type and specialty, if any;
(III) reasons for request denial;
(IV) denials overturned on internal
appeal;
(V) denials overturned by
an independent review organization; and
(VI) total annual preauthorization requests,
approvals, and denials for the service.
(3) This subsection may not be
construed to require an HMO or a preferred provider benefit plan to provide
specific information that would violate any applicable copyright law or
licensing agreement. To comply with a posting requirement described by
paragraph (2) of this subsection, an HMO or a preferred provider benefit plan
may, instead of making that information publicly available on the HMO's or the
preferred provider benefit plan's public internet website, supply a summary of
the withheld information sufficient to allow a licensed physician or other
health care provider, as applicable for the specific service, who has
sufficient training and experience related to the service to understand the
basis for the HMO's or the preferred provider benefit plan's medical necessity
or appropriateness determinations.
(4) If a requirement or information described
by paragraph (1) of this subsection is licensed, proprietary, or copyrighted
material that the HMO or the preferred provider benefit plan has received from
a third party with which the HMO or the preferred provider benefit plan has
contracted, to comply with a posting requirement described by paragraph (2) of
this subsection, the HMO or the preferred provider benefit plan may, instead of
making that information publicly available on the HMO's or the preferred
provider benefit plan's public internet website, provide the material to a
physician or health care provider who submits a preauthorization request using
a nonpublic secured internet website link or other protected, nonpublic
electronic means.
(5) The
provisions in this paragraph apply when an HMO or a preferred provider benefit
plan makes changes to preauthorization requirements.
(A) Except as provided by subparagraph (B) of
this paragraph, not later than the 60th day before the date a new or amended
preauthorization requirement takes effect, an HMO or a preferred provider
benefit plan must provide notice of the new or amended preauthorization
requirement and disclose the new or amended requirement in the HMO's or the
preferred provider benefit plan's newsletter or network bulletin, if any, and
on the HMO's or the preferred provider benefit plan's public internet
website.
(B) For a change in a
preauthorization requirement or process that removes a service from the list of
medical and health care services requiring preauthorization or amends a
preauthorization requirement in a way that is less burdensome to enrollees or
participating physicians or health care providers, an HMO or a preferred
provider benefit plan must provide notice of the change in the preauthorization
requirement and disclose the change in the HMO's or the preferred provider
benefit plan's newsletter or network bulletin, if any, and on the HMO's or the
preferred provider benefit plan's public internet website not later than the
fifth day before the date the change takes effect.
(C) Not later than the fifth day before the
date a new or amended preauthorization requirement takes effect, an HMO or a
preferred provider benefit plan must update its public internet website to
disclose the change to the HMO's or the preferred provider benefit plan's
preauthorization requirements or process and the date and time the change is
effective.
(6) In
addition to any other penalty or remedy provided by law, an HMO or a preferred
provider benefit plan that uses a preauthorization process for medical or
health care services that violates this section with respect to a required
publication, notice, or response regarding its preauthorization requirements,
including by failing to comply with any applicable deadline for the
publication, notice, or response, must provide an expedited appeal under
Insurance Code §
4201.357 for any
health care service affected by the violation. This paragraph does not apply to
subsections (f), (k), and (l) of this section.
(7) The provisions of this subsection may not
be waived, voided, or nullified by contract.
(k) The provisions of this subsection apply
to dental care services under an employee benefit plan or health insurance
policy that require prior authorization.
(1)
In this subsection, the definitions in Texas Insurance Code §
1451.201 for "dental
care service," "employee benefit plan," and "health insurance policy"
apply.
(2) In this subsection,
"prior authorization" means a written and verifiable determination that one or
more specific dental care services are covered under the patient's employee
benefit plan or health insurance policy and are payable and reimbursable in a
specific stated amount, subject to applicable coinsurance and deductible
amounts. The term includes preauthorization and similar authorization. The term
does not include predetermination as that term is defined by Insurance Code
§
1451.207(c).
(3) For services for which a prior
authorization is required, on request of a patient or treating dentist, an
employee benefit plan or health insurance policy provider or issuer must
provide to the dentist a written prior authorization of benefits for a dental
care service for the patient. The prior authorization must include a specific
benefit payment or reimbursement amount. Except as provided by paragraph (4) of
this subsection, the plan or policy provider or issuer may not pay or reimburse
the dentist in an amount that is less than the amount stated in the prior
authorization.
(4) An employee
benefit plan or health insurance policy provider or issuer that preauthorizes a
dental care service under paragraph (3) of this subsection may deny a claim for
the dental care service or reduce payment or reimbursement to the dentist for
the service only if:
(A) the denial or
reduction is in accordance with the patient's employee benefit plan or health
insurance policy benefit limitations, including an annual maximum or frequency
of treatment limitation, and the patient met the benefit limitation after the
date the prior authorization was issued;
(B) the documentation for the claim fails to
reasonably support the claim as preauthorized;
(C) the preauthorized dental service was not
medically necessary based on the prevailing standard of care on the date of the
service, or is subject to denial under the conditions for coverage under the
patient's plan or policy in effect at the time the service was preauthorized,
because of a change in the patient's condition or because the patient received
additional dental care after the date the prior authorization was
issued;
(D) a payor other than the
employee benefit plan or health insurance policy provider or issuer is
responsible for payment of the claim;
(E) the dentist received full payment for the
preauthorized dental care service on which the claim is based;
(F) the claim is fraudulent;
(G) the prior authorization was based wholly
or partly on a material error in information provided to the employee benefit
plan or health insurance policy provider or issuer by any person not related to
the provider or the issuer; or
(H)
the patient was otherwise ineligible for the dental care service under the
patient's employee benefit plan or health insurance policy and the plan or
policy issuer did not know, and could not reasonably have known, that the
patient was ineligible for the dental care service on the date the prior
authorization was issued.
(l) 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 heath benefit plan issuer
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. When practicable, a
URA must review and issue a determination on a renewal request before the
existing preauthorization expires if the URA receives the request before the
existing preauthorization expires. The determination must indicate whether the
medical or health care service is preauthorized.