Current through Reg. 50, No. 13; March 28, 2025
(a) The words and
terms defined in Insurance Code Chapter 1301, concerning Preferred Provider
Benefit Plans, and Chapter 843, concerning Health Maintenance Organizations,
have the same meaning when used in this section, except as otherwise provided
by this subchapter, unless the context clearly indicates otherwise. This
section applies to:
(2) preferred provider benefit
plans;
(3) preferred providers;
and
(4) physicians, doctors, or
other health care providers that provide to an enrollee of an HMO or preferred
provider benefit plan:
(A) care related to an
emergency or its attendant episode of care as required by state or federal law;
or
(B) specialty or other medical
care or health care services at the request of the HMO, preferred provider
benefit plan, or a preferred provider because the services are not reasonably
available from a preferred provider who is included in the HMO or preferred
provider benefit plan's network.
(b) An HMO or preferred provider benefit plan
must be able to receive a request for verification of proposed medical care or
health care services:
(3) by other means, including the Internet,
as agreed to by the preferred provider and the HMO or preferred provider
benefit plan, provided that the agreement may not limit the preferred
provider's option to request a verification by telephone call.
(c) An HMO or preferred provider
benefit plan must have appropriate personnel reasonably available at a
toll-free telephone number under Insurance Code §
1301.133. The HMO or
preferred provider benefit plan must acknowledge calls not later than:
(1) for requests relating to
post-stabilization care or a life-threatening condition, within one hour after
the beginning of the next time period requiring the availability of appropriate
personnel at the toll-free telephone number;
(2) for requests relating to concurrent
hospitalization, within 24 hours after the beginning of the next time period
requiring the availability of appropriate personnel at the toll-free telephone
number; and
(3) for all other
requests, within two calendar days after the beginning of the next time period
requiring the availability of appropriate personnel at the toll-free telephone
number.
(d) Any request
for verification must contain the following information:
(2) enrollee ID number, if included on an
identification card issued by the HMO or preferred provider benefit
plan;
(3) enrollee date of
birth;
(4) name of enrollee or
subscriber, if included on an identification card issued by the HMO or
preferred provider benefit plan;
(5) enrollee relationship to enrollee or
subscriber;
(6) presumptive
diagnosis, if known; otherwise presenting symptoms;
(7) description of proposed procedures or
procedure codes;
(8) place of
service code where services will be provided and, if place of service is other
than provider's office or provider's location, name of hospital or facility
where proposed service will be provided;
(9) proposed date of service;
(10) group number, if included on an
identification card issued by the HMO or preferred provider benefit
plan;
(11) if known to the
provider, name and contact information of any other carrier, including the
name, address, and telephone number; name of enrollee; plan or ID number; group
number (if applicable); and group name (if applicable);
(12) name of provider providing the proposed
services; and
(13) provider's
federal tax ID number.
(e) Receipt of a written request or a written
response to a request for verification under this section is subject to the
provisions of §
21.2816 of this title (relating to
Date of Receipt).
(f) If necessary
to verify proposed medical care or health care services, an HMO or preferred
provider benefit plan may, within one day of receipt of a request for
verification, request information from the preferred provider in addition to
the information provided in the request for verification. An HMO or preferred
provider benefit plan may make only one request for additional information from
the requesting preferred provider under this section.
(g) A request for information under
subsection (f) of this section must:
(1) be
specific to the verification request;
(2) describe with specificity the clinical
and other information to be included in the response;
(3) be relevant and necessary for the
resolution of the request; and
(4)
be for information contained in or in the process of being incorporated into
the enrollee's medical or billing record maintained by the preferred
provider.
(h) On receipt
of a request for verification from a preferred provider, an HMO or preferred
provider benefit plan must issue a verification or declination. The HMO or
preferred provider benefit plan must issue the verification or declination
within the following time periods.
(1) Except
as provided in paragraphs (2) and (3) of this subsection, an HMO or preferred
provider benefit plan must provide a verification or declination in response to
a request for verification without delay, and as appropriate to the
circumstances of the particular request, but not later than five calendar days
after the date of receipt of the request for verification. If the request is
received outside of the period requiring the availability of appropriate
personnel as required in subsection (c) of this section, the determination must
be provided within five calendar days from the beginning of the next time
period requiring appropriate personnel.
(2) If the request is related to a concurrent
hospitalization, the response must be sent to the preferred provider without
delay but not later than 24 hours after the HMO or preferred provider benefit
plan received the request for verification. If the request is received outside
of the period requiring the availability of appropriate personnel as required
in subsection (c) of this section, the determination must be provided within 24
hours from the beginning of the next time period requiring appropriate
personnel.
(3) If the request is
related to post-stabilization care or a life-threatening condition, the
response must be sent to the preferred provider without delay but not later
than one hour after the HMO or preferred provider benefit plan received the
request for verification. If the request is received outside of the period
requiring the availability of appropriate personnel as required in subsections
(c) and (d) of this section, the determination must be provided within one hour
from the beginning of the next time period requiring appropriate
personnel.
(i) If the
request involves services for which preauthorization is required, the HMO or
preferred provider benefit plan must implement the procedures set forth in
§
19.1718 of this title (relating to
Preauthorization for Health Maintenance Organizations and Preferred Provider
Benefit Plans) and respond regarding the preauthorization request in compliance
with that section.
(j) A
verification or declination may be delivered via telephone call, in writing, or
by other means, including the Internet, as agreed to by the preferred provider
and the HMO or preferred provider benefit plan. If a verification or
declination is delivered via telephone call, the HMO or preferred provider
benefit plan must, within three calendar days of providing a verbal response,
provide a written response which must include, at a minimum:
(3) requesting provider's name;
(4) hospital or other facility name, if
applicable;
(5) a specific
description, including relevant procedure codes, of the services that are
verified or declined;
(6) if the
services are verified, the effective period for the verification, which must
not be less than 30 calendar days from the date of verification;
(7) if the services are verified, any
applicable deductibles, copayments, or coinsurance for which the enrollee is
responsible;
(8) if the
verification is declined, the specific reason for the declination;
(9) a unique verification number that allows
the HMO or preferred provider benefit plan to match the verification and
subsequent claims related to the proposed service; and
(10) a statement that the proposed services
are being verified or declined.
