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 19.1733 - Retrospective Reviews and Appeals of Preauthorization Exemption Rescissions

Current through Reg. 49, No. 28; July 12, 2024
(a) For a retrospective review that is
					 conducted under Insurance Code § 4201.659(b)(1), concerning Effect of
					 Preauthorization Exemption, to determine whether the physician or provider
					 still qualifies for an exemption, Insurance Code §
											4201.305,
					 concerning Notice of Adverse Determination for Retrospective Utilization
					 Review, does not apply.
(b) An
					 issuer that is conducting an evaluation as defined in § 19.1730(4)(B) of
					 this title (relating to Definitions) to determine whether a physician or
					 provider still qualifies for a preauthorization exemption may request medical
					 records or other documents, consistent with §
											19.1707
					 of this title (relating to URA Contact with and Receipt of Information from
					 Health Care Providers), and must provide at least 30 days for a physician or
					 provider to provide the records. Medical records requested in connection with a
					 retrospective review of a random sample of claims as authorized under Insurance
					 Code § 4201.659(b)(1) should be limited to no more than 20 claims for a
					 particular health care service and may be requested only during an evaluation
					 period or within 90 days following the end of an evaluation period. If the
					 physician or provider fails to provide the records necessary for the issuer to
					 make a determination, the issuer may determine that the claim would not have
					 met the screening criteria.
(c)
					 After receiving a notice of rescission, a physician or provider may request an
					 independent review of the adverse determination regarding a preauthorization
					 exemption at any time before the rescission becomes effective. The date of the
					 request must be documented on the form, and the form must be sent
					 electronically or postmarked before the date the rescission becomes
					 effective.
(d) In order to request
					 an independent review of a rescission of a preauthorization exemption, a
					 physician or provider must submit the form provided by the issuer under §
					 19.1732(c) of this title (relating to Notice of Preauthorization Exemption
					 Grants, Denials, or Rescissions). If one or more determinations subject to
					 review were based on a failure to provide specified medical records, the
					 physician or provider must include the applicable records with the request for
					 an independent review. Upon receipt, if the issuer seeks to proceed with the
					 proposed rescission, the issuer must submit the request for independent review
					 to the department, consistent with § 12.601 of this title (relating to
					 Preauthorization Exemptions), and §
											19.1717(c)
					 of this title (relating to Independent Review of Adverse Determinations), and
					 provide information to the IRO consistent with Insurance Code §
											4201.402.
(e) If the notice of rescission of
					 preauthorization exemption identified that at least five additional claims were
					 eligible for review but not included in the original random sample, the
					 physician or provider may request review of another random sample of claims, as
					 authorized under Insurance Code § 4201.656(d). If this request is made,
					 the issuer must, when submitting the request for independent review to the
					 department, provide a listing of all payable claims for the same health care
					 service submitted by or in connection with the physician or provider during the
					 most recent evaluation period that were eligible to be evaluated but that were
					 not included in the original random sample. The listing must be sufficiently
					 detailed to allow the IRO to identify each payable claim to be used in an
					 additional random sample, as provided by § 12.601(e) of this
					 title.
(f) An issuer must
					 communicate the determination of a review by an independent review organization
					 under § 12.601 of this title to the physician or provider within five
					 days.
(g) In order to retain a
					 preauthorization exemption, a physician or provider must continue to maintain
					 medical records adequate to demonstrate that health care services meet medical
					 guidelines. In the absence of adequate records during an evaluation or appeal,
					 an exemption may be rescinded.