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 19.1732 - Notice of Preauthorization Exemption Grants, Denials, or Rescissions

Current through Reg. 49, No. 28; July 12, 2024
(a) When granting a preauthorization
					 exemption, an issuer must provide notice to the physician or provider,
					 consistent with Insurance Code § 4201.659(d), concerning Effect of
					 Preauthorization Exemption. The notice must include a plain language
					 explanation of the effect of the preauthorization exemption and any claim
					 coding guidance needed to document the preauthorization exemption, consistent
					 with § 19.1731(e) of this title (relating to Preauthorization Exemption).
					 The exemption begins on the date the notice is issued and must be in place for
					 at least six months before it may be rescinded. If an issuer subsequently
					 receives a preauthorization request from the physician or provider for a
					 particular health care service for which an exemption has been granted, the
					 issuer must provide a notice consistent with Insurance Code §
					 4201.659(e).
(b) When denying a
					 preauthorization exemption, an issuer must provide notice to the physician or
					 provider that demonstrates that the physician or provider does not meet the
					 criteria for a preauthorization exemption, consistent with Insurance Code
					 § 4201.655(c)(2), concerning Denial or Rescission of Preauthorization
					 Exemption; a description of how to appeal the denial using the issuer's
					 complaints and appeals processes; and information on how to file a complaint
					 with the department.
(c) After
					 completing an evaluation as defined under § 19.1730(4)(A) of this title
					 (relating to Definitions), an issuer must provide a notice granting or denying
					 a preauthorization exemption within five days. For the initial evaluation
					 period of January 1 through June 30, 2022, an issuer must provide notice
					 granting or denying a preauthorization exemption no later than October 1, 2022.
					 For subsequent evaluation periods during which a physician or provider does not
					 have a preauthorization exemption, an issuer must provide notice to the
					 physician or provider granting or denying a preauthorization exemption no later
					 than two months following the day after the end of the evaluation period.
					 Notice need only be provided for a particular health care service if the issuer
					 was able to complete an evaluation of at least five eligible preauthorization
					 requests, as provided in § 19.1731(b) of this title.
(d) When rescinding a preauthorization
					 exemption, an issuer must provide notice to the physician or provider,
					 consistent with Insurance Code § 4201.655(a)(3). Notice of the rescission
					 must be provided during the months specified in Insurance Code §
					 4201.655(a)(1). The notice must include the following (a sample form LHL011 is
					 available on TDI's website):
(1) an
					 identification of the health care service for which a preauthorization
					 exemption is being rescinded, the date the notice is issued, and the date the
					 rescission is effective, consistent with Insurance Code § 4201.654,
					 concerning Duration of Preauthorization Exemption;
(2) a plain language explanation of how the
					 physician or provider may appeal and seek an independent review of the
					 determination, the date the notice is issued, and the company's address and
					 contact information for returning the form by mail or electronic means to
					 request an appeal;
(3) a statement
					 of the total number of payable claims submitted by or in connection with the
					 physician or provider during the most recent evaluation period that were
					 eligible to be evaluated with respect to the health care service subject to
					 rescission, the number of claims included in the random sample, and the sample
					 information used to make the determination, including:
(A) identification of each claim included in
					 the random sample;
(B) the issuer's
					 determination of whether each claim met the issuer's screening criteria;
					 and
(C) for any claim determined to
					 not have met the issuer's screening criteria:
(i) the principal reasons for the
					 determination that the claim did not meet the issuer's screening criteria,
					 including, if applicable, a statement that the determination was based on a
					 failure to submit specified medical records;
(ii) the clinical basis for the determination
					 that the claim did not meet the issuer's screening criteria;
(iii) a description of the sources of the
					 screening criteria that were used as guidelines in making the determination;
					 and
(iv) the professional specialty
					 of the physician, doctor, or other health care provider who made the
					 determination;
(4) a space to be filled out by the physician
					 or provider that includes:
(A) the name,
					 address, contact information, and identification number of the physician or
					 provider requesting an independent review;
(B) an indication of whether the physician or
					 provider is requesting that the independent review organization review the same
					 random sample or a different random sample of claims, if available;
					 and
(C) the date the appeal is
					 being requested; and
(5)
					 an instruction for the physician or provider to return the form to the issuer
					 before the date the rescission becomes effective and to include applicable
					 medical records for any determination that was based on a failure to provide
					 medical records.