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 2 - PREAUTHORIZATION EXEMPTIONS › Section 19.1730 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms have the following meanings
						when used in this subchapter unless the context clearly indicates
						otherwise.
(1) Adverse determination
					 regarding a preauthorization exemption--A decision by an issuer that one or
					 more claims retrospectively reviewed as part of an evaluation as defined in
					 paragraph (4)(B) of this section, with respect to a particular health care
					 service for which the physician or provider has a preauthorization exemption,
					 did not meet the issuer's screening criteria, and leads to an issuer's decision
					 to rescind a preauthorization exemption. An adverse determination regarding a
					 preauthorization exemption is not an adverse determination as defined under
					 §
											19.1703 of
					 this title (relating to Definitions).
(2) Denial of preauthorization exemption--A
					 determination that a physician or provider does not qualify for a
					 preauthorization exemption based on the issuer conducting an evaluation, as
					 defined in paragraph (4)(A) of this section, of eligible preauthorization
					 requests and demonstrating that the physician or provider received approval for
					 fewer than 90% of the eligible preauthorization requests made for a particular
					 health care service during the most recent evaluation period.
(3) Eligible preauthorization request--A
					 preauthorization request for a particular health care service is eligible for
					 the purposes of an evaluation under paragraph (4)(A) of this section if it is
					 submitted by the physician or provider and finalized by the health plan during
					 the evaluation period, is not pending appeal, and has an outcome of either
					 approving the particular health care service or issuing an adverse
					 determination for the particular health care service. A preauthorization
					 request that is modified with the acceptance of the physician or provider and
					 approved by the plan as modified is an eligible preauthorization request for
					 the purpose of conducting an evaluation under this section, with respect to the
					 particular health care service that was approved. If a preauthorization request
					 includes more than one particular health care service, the outcome for each
					 service must be counted separately for the purposes of an evaluation.
(4) Evaluation--
(A) with respect to a particular health care
					 service for which a physician or provider does not have a preauthorization
					 exemption, a review of the outcomes of eligible preauthorization requests
					 submitted by the physician or provider during the most recent evaluation period
					 to determine the percentage of requests that were approved, which is conducted
					 for the purpose of evaluating whether to grant or deny a preauthorization
					 exemption; or
(B) with respect to a
					 particular health care service for which a physician or provider has a
					 preauthorization exemption, a retrospective review of a random sample of
					 payable claims submitted by or in connection with the physician or provider
					 during the most recent evaluation period to determine the percentage of claims
					 that would have been approved, based on meeting the issuer's applicable medical
					 necessity criteria at the time the service was provided, which is conducted for
					 the purpose of evaluating whether to continue or rescind a preauthorization
					 exemption and consistent with Insurance Code § 4201.655, concerning Denial
					 or Rescission of Preauthorization Exemption.