2023 Texas Statutes › Insurance Code › Title 6 - Organization of Insurers and Related Entities › Subtitle C - Life, Health, and Accident Insurers and Related Entities › Chapter 843 - Health Maintenance Organizations › Subchapter J. Payment of Claims to Physicians and Providers › Section 843.3481. Posting of Preauthorization Requirements

Sec. 843.3481.  POSTING OF PREAUTHORIZATION REQUIREMENTS.  (a)  A health maintenance organization that uses a preauthorization process for health care services shall make the requirements and information about the preauthorization process readily accessible to enrollees, physicians, providers, and the general public by posting the requirements and information on the health maintenance organization'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 enrollees, physicians, 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 the health care services for which the health maintenance organization 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 health maintenance organization requires from the physician or provider ordering or requesting the service to approve a request for that service;
(C)  the applicable screening criteria, which may include Current Procedural Terminology codes and International Classification of Diseases codes; and
(D)  statistics regarding preauthorization approval and denial rates for the service in the preceding calendar year, including statistics in the following categories:
(i)  physician or 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 a health maintenance organization to provide specific information that would violate any applicable copyright law or licensing agreement.  To comply with a posting requirement described by Subsection (b), a health maintenance organization may, instead of making that information publicly available on the health maintenance organization's Internet website, supply a summary of the withheld information sufficient to allow a licensed physician or provider, as applicable for the specific service, who has sufficient training and experience related to the service to understand the basis for the health maintenance organization's medical necessity or appropriateness determinations.
(d)  If a requirement or information described by Subsection (a) is licensed, proprietary, or copyrighted material that the health maintenance organization has received from a third party with which the health maintenance organization has contracted, to comply with a posting requirement described by Subsection (b), the health maintenance organization may, instead of making that information publicly available on the health maintenance organization's Internet website, provide the material to a physician or provider who submits a preauthorization request using a nonpublic secured Internet website link or other protected, nonpublic electronic means.
Added by Acts 2019, 86th Leg., R.S., Ch. 1218 (S.B. 1742), Sec. 2.02, eff. September 1, 2019.
Sec. 843.3482.  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, a health maintenance organization that uses a preauthorization process for health care services shall provide notice of the new or amended preauthorization requirement and disclose the new or amended requirement in the health maintenance organization's newsletter or network bulletin, if any, and on the health maintenance organization's Internet website.
(b)  For a change in a preauthorization requirement or process that removes a service from the list of health care services requiring preauthorization or amends a preauthorization requirement in a way that is less burdensome to enrollees or participating physicians or providers, a health maintenance organization shall provide notice of the change in the preauthorization requirement and disclose the change in the health maintenance organization's newsletter or network bulletin, if any, and on the health maintenance organization'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, a health maintenance organization shall update its Internet website to disclose the change to the health maintenance organization's preauthorization requirements or process and the date and time the change is effective.
Added by Acts 2019, 86th Leg., R.S., Ch. 1218 (S.B. 1742), Sec. 2.02, eff. September 1, 2019.