Texas Administrative Code
Title 28 - INSURANCE
Part 1 - TEXAS DEPARTMENT OF INSURANCE
Chapter 21 - TRADE PRACTICES
Subchapter P - MENTAL HEALTH PARITY
Division 2 - PLAN INFORMATION AND DATA COLLECTION
Section 21.2425 - Claims and Utilization Review: Reporting Classifications

Universal Citation: 28 TX Admin Code § 21.2425

Current through Reg. 50, No. 13; March 28, 2025

(a) Separate reporting. Within the "MH/SUD Parity Rule Division 2 Data Collection Reporting Form" template, in the worksheet titled "Claims and Utilization Review," an issuer must separately report claims and requests for utilization review for medical/surgical and MH/SUD.

(b) ICD diagnosis codes. In the worksheet titled "Claims and Utilization Review," all claims and utilization review requests with mental, behavioral, and neurodevelopmental disorder diagnosis codes in the International Classification of Diseases and Related Health Problems should be categorized as MH/SUD. Claims and utilization review requests with all other ICD diagnostic codes should be categorized as medical/surgical.

(c) Reporting classifications. Claims and requests for utilization review are to be identified in the worksheet as belonging in one the following reporting classifications:

(1) inpatient, in-network;

(2) inpatient, out-of-network;

(3) outpatient, in-network, consisting of:
(A) office visits; and

(B) all other;

(4) outpatient, out-of-network, consisting of:
(A) office visits; and

(B) all other;

(5) emergency; and

(6) prescription drugs.

(d) Unneeded information. Where appropriate, an issuer may enter "N/A" in the worksheet. For example, indemnity plans will not have data for in-network classifications, and HMOs with no POS component and EPOs will not have data for out-of-network classifications. An issuer of those plans may therefore enter N/A where that data is requested.

Disclaimer: These regulations may not be the most recent version. Texas may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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