Texas Administrative Code
Title 28 - INSURANCE
Part 1 - TEXAS DEPARTMENT OF INSURANCE
Chapter 21 - TRADE PRACTICES
Subchapter W - COVERAGE FOR ACQUIRED BRAIN INJURY
Section 21.3104 - Training

Universal Citation: 28 TX Admin Code § 21.3104

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

(a) In this section, "preauthorization" has the meaning assigned by Insurance Code § 1352.004(a), and includes benefit determinations for proposed medical or health care services.

(b) Each issuer must develop written preauthorization and utilization review policies and procedures for the purpose of identifying services to be covered for acquired brain injury, to be used by any individual responsible for preauthorization of coverage or utilization review. Such policies and procedures must include:

(1) identification of all current Common Procedural Terminology (CPT) codes associated with services for acquired brain injury; and

(2) a means to identify an enrollee initially diagnosed with an acquired brain injury.

(c) Each health benefit plan issuer must ensure that all employees or staff responsible for preauthorization of coverage or utilization review, or any individual performing these processes, receive training to prevent wrongful denial of coverage required under Insurance Code Chapter 1352 and this subchapter, and to avoid confusion of medical and surgical benefits with mental and behavioral health benefits. At a minimum, training must consist of:

(1) identification of services likely to be requested in treating an enrollee with an acquired brain injury;

(2) identification of specific therapies currently used in treating an enrollee with an acquired brain injury;

(3) instruction relating to correctly evaluating requests for services to differentiate between covered medical and surgical benefits versus covered benefits for mental and behavioral health; and

(4) instruction relating to the requirements of Insurance Code Chapter 1352 and this subchapter.

(d) At a minimum, training must be accomplished by attendance at an initial orientation, in-service, or continuing education program relating to acquired brain injuries and their treatments, provided that the training is consistent with the requirements of subsections (a) and (b) of this section.

(1) Documentation and verification of training must be maintained for each employee or staff member responsible for preauthorization of coverage, utilization review, or any individual performing these processes.

(2) On request, any documentation and verification required by paragraph (1) of this subsection must be provided to the issuer with whom the employee, staff member, or individual is employed or contracted.

(3) On request, any documentation and verification required by paragraph (1) of this subsection must be provided to the department for review.

(e) The requirements of this section also apply to any contracted entity of an issuer to the extent the contracted entity is responsible for preauthorization or utilization review.

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