2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter C. -1. Other Provisions Relating to Payment of Claims › Section 1301.1351. Posting of Preauthorization Requirements

Sec. 1301.1351.  POSTING OF PREAUTHORIZATION REQUIREMENTS.  (a)  An insurer that uses a preauthorization process for medical care or health care services shall make the requirements and information about the preauthorization process readily accessible to insureds, physicians, health care providers, and the general public by posting the requirements and information on the insurer's Internet website.
(b)  The preauthorization requirements and information described by Subsection (a) must:
(1)  be posted:
(A)  except as provided by Subsection (c) or (d), conspicuously in a location on the Internet website that does not require the use of a log-in or other input of personal information to view the information; and
(B)  in a format that is easily searchable and accessible;
(2)  except for the screening criteria under Subdivision (4)(C), be written in plain language that is easily understandable by insureds, physicians, health care providers, and the general public;
(3)  include a detailed description of the preauthorization process and procedure; and
(4)  include an accurate and current list of medical care and health care services for which the insurer requires preauthorization that includes the following information specific to each service:
(A)  the effective date of the preauthorization requirement;
(B)  a list or description of any supporting documentation that the insurer requires from the physician or health care provider ordering or requesting the service to approve a request for the service;
(C)  the applicable screening criteria, which may include Current Procedural Terminology codes and International Classification of Diseases codes; and
(D)  statistics regarding the insurer's preauthorization approval and denial rates for the medical care or health care service in the preceding calendar year, including statistics in the following categories:
(i)  physician or health care provider type and specialty, if any;
(ii)  indication offered;
(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.
(c)  This section may not be construed to require an insurer to provide specific information that would violate any applicable copyright law or licensing agreement.  To comply with a posting requirement described by Subsection (b), an insurer may, instead of making that information publicly available on the insurer's 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 insurer's medical necessity or appropriateness determinations.
(d)  If a requirement or information described by Subsection (a) is licensed, proprietary, or copyrighted material that the insurer has received from a third party with which the insurer has contracted, to comply with a posting requirement described by Subsection (b), the insurer may, instead of making that information publicly available on the insurer's 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.
(e)  The provisions of this section may not be waived, voided, or nullified by contract.
Added by Acts 2019, 86th Leg., R.S., Ch. 1218 (S.B. 1742), Sec. 2.04, eff. September 1, 2019.
Sec. 1301.1352.  CHANGES TO PREAUTHORIZATION REQUIREMENTS.  (a)  Except as provided by Subsection (b), not later than the 60th day before the date a new or amended preauthorization requirement takes effect, an insurer that uses a preauthorization process for medical care or health care services shall provide notice of the new or amended preauthorization requirement and disclose the new or amended requirement in the insurer's newsletter or network bulletin, if any, and on the insurer's Internet website.
(b)  For a change in a preauthorization requirement or process that removes a service from the list of medical care or health care services requiring preauthorization or amends a preauthorization requirement in a way that is less burdensome to insureds, physicians, or health care providers, an insurer shall provide notice of the change in the preauthorization requirement and disclose the change in the insurer's newsletter or network bulletin, if any, and on the insurer's 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 insurer shall update its Internet website to disclose the change to the insurer's preauthorization requirements or process and the date and time the change is effective.
(d)  The provisions of this section may not be waived, voided, or nullified by contract.
Added by Acts 2019, 86th Leg., R.S., Ch. 1218 (S.B. 1742), Sec. 2.04, eff. September 1, 2019.