Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 19 - LICENSING AND REGULATION OF INSURANCE PROFESSIONALS › Subchapter R - UTILIZATION REVIEWS FOR HEALTH CARE PROVIDED UNDER A HEALTH BENEFIT PLAN OR HEALTH INSURANCE POLICY › Division 1 - UTILIZATION REVIEWS › Section 19.1718 - Preauthorization for Health Maintenance Organizations and Preferred Provider Benefit Plans

Current through Reg. 49, No. 28; July 12, 2024
(a) The words and
					 terms defined in Insurance Code Chapter 1301 and Chapter 843 have the same
					 meaning when used in this section, except as otherwise provided by this
					 subchapter, unless the context clearly indicates otherwise.
(b) An HMO or preferred provider benefit plan
					 that requires preauthorization as a condition of payment to a preferred
					 provider must comply with the procedures of this section for determinations of
					 medical necessity, appropriateness, or the experimental or investigational
					 nature of care for those services the HMO or preferred provider benefit plan
					 identifies under subsection (c) of this section.
(c) An HMO or preferred provider benefit plan
					 that uses a preauthorization process for medical care or health care services
					 must provide to each contracted preferred provider, not later than the fifth
					 working day after the date a request is made, a list of medical care and health
					 care services that allows a preferred provider to determine which services
					 require preauthorization and information concerning the preauthorization
					 process.
(d) An HMO or preferred
					 provider benefit plan must issue and transmit a determination indicating
					 whether the proposed medical or health care services are preauthorized. This
					 determination must be issued and transmitted once a preauthorization request
					 for proposed services that require preauthorization is received from a
					 preferred provider. The HMO or preferred provider benefit plan must respond to
					 a request for preauthorization within the following time periods:
(1) For services not included under
					 paragraphs (2) and (3) of this subsection, a determination must be issued and
					 transmitted not later than the third calendar day after the date the request is
					 received by the HMO or preferred provider benefit plan. If the request is
					 received outside of the period requiring the availability of appropriate
					 personnel as required in subsections (e) and (f) of this section, the
					 determination must be issued and transmitted within three calendar days from
					 the beginning of the next time period requiring appropriate
					 personnel.
(2) If the proposed
					 medical or health care services are for concurrent hospitalization care, the
					 HMO or preferred provider benefit plan must issue and transmit a determination
					 indicating whether proposed services are preauthorized within 24 hours of
					 receipt of the request, followed within three working days after the
					 transmittal of the determination by a letter notifying the enrollee or the
					 individual acting on behalf of the enrollee and the provider of record of an
					 adverse determination. If the request for medical or health care services for
					 concurrent hospitalization care is received outside of the period requiring the
					 availability of appropriate personnel as required in subsections (e) and (f) of
					 this section, the determination must be issued and transmitted within 24 hours
					 from the beginning of the next time period requiring appropriate
					 personnel.
(3) If the proposed
					 medical care or health care services involve post-stabilization treatment, or a
					 life-threatening condition as defined in §
												19.1703 of
					 this title (relating to Definitions), the HMO or preferred provider benefit
					 plan must issue and transmit a determination indicating whether proposed
					 services are preauthorized within the time appropriate to the circumstances
					 relating to the delivery of the services and the condition of the enrollee, but
					 in no case to exceed one hour from receipt of the request. If the request is
					 received outside of the period requiring the availability of appropriate
					 personnel as required in subsections (e) and (f) of this section, the
					 determination must be issued and transmitted within one hour from the beginning
					 of the next time period requiring appropriate personnel. The determination must
					 be provided to the provider of record. If the HMO or preferred provider benefit
					 plan issues an adverse determination in response to a request for
					 post-stabilization treatment or a request for treatment involving a
					 life-threatening condition, the HMO or preferred provider benefit plan must
					 provide to the enrollee or individual acting on behalf of the enrollee, and the
					 enrollee's provider of record, the notification required by §
												19.1717(a)
					 and (b) of this title (relating to
					 Independent Review of Adverse Determinations).