Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 19 - LICENSING AND REGULATION OF INSURANCE PROFESSIONALS › Subchapter S - FORMS TO REQUEST PRIOR AUTHORIZATION › Division 2 - TEXAS STANDARDIZED PRIOR AUTHORIZATION REQUEST FORM FOR HEALTH CARE SERVICES › Section 19.1810 - Prior Authorization Request Form for Health Care Services, Required Acceptance, and Use

Current through Reg. 49, No. 28; July 12, 2024
(a) Form
					 requirements. The commissioner adopts by reference the Prior Authorization
					 Request Form for Health Care Services, to be accepted and used by an issuer in
					 compliance with subsection (b) of this section. The form and its instruction
					 sheet are posted on the TDI website at
www.tdi.texas.gov/forms/form10.html
;
					 or the form and its instruction sheet can be requested by mail from the Texas
					 Department of Insurance, Rate and Form Review Office, MC: LH-MCQA, P.O. Box
					 12030, Austin, Texas 78711-2030. The form must be reproduced without changes.
					 The form provides space for the following information:
(1) the plan issuer's name, telephone number,
					 and facsimile (fax) number;
(2) the
					 date the request is submitted;
(3)
					 the type of review, whether:
(A) nonurgent;
					 or
(B) urgent. An urgent review
					 should only be requested for a patient with a life-threatening condition or for
					 a patient who is currently hospitalized, or to authorize treatment following
					 stabilization of an emergency condition. A provider or facility may also
					 request an urgent review to authorize treatment of an acute injury or illness
					 if the provider determines that the condition is severe or painful enough to
					 warrant an expedited or urgent review to prevent a serious deterioration of the
					 patient's condition or health;
(4) the type of request (whether an initial
					 request or an extension, renewal, or amendment of a previous
					 authorization);
(5) the patient's
					 name, date of birth, sex, contact telephone number, and identifying insurance
					 information;
(6) the requesting
					 provider's or facility's name, NPI number, specialty, telephone and fax
					 numbers, contact person's name and telephone number, and the requesting
					 provider's signature and date, if required (if a signature is required, a
					 signature stamp may not be used);
(7) the service provider's or facility's
					 name, NPI number, specialty, and telephone and fax numbers;
(8) the primary care provider's name and
					 telephone and fax numbers, if the patient's plan requires the patient to have a
					 primary care provider and that provider is not the requesting
					 provider;
(9) the planned services
					 or procedures and the associated CPT, CDT, or HCPCS codes, and the planned
					 start and end dates of the services or procedures;
(10) the diagnosis description, ICD version
					 number (if more than one version is allowed by the U.S. Department of Health
					 and Human Services), and ICD code;
(11) identification of the treatment location
					 (inpatient, outpatient, provider office, observation, home, day surgery, or
					 other specified location);
(12)
					 information about the duration and frequency of treatment sessions for
					 physical, occupational, or speech therapy, cardiac rehabilitation, mental
					 health, or substance abuse;
(13) if
					 requesting prior authorization for home health care, information about the
					 requested number of home health visits and their duration and frequency, and an
					 indication whether a physician's signed order or a nursing assessment is
					 attached;
(14) if requesting prior
					 authorization for durable medical equipment, an indication whether a
					 physician's signed order is attached, a description of requested equipment or
					 supplies with associated HCPCS codes, duration, and, if the patient is a
					 Medicaid beneficiary, an indication whether a Title 19 Certification is
					 attached;
(15) a place for the
					 requester to include a brief narrative of medical necessity or other clinical
					 documentation. A requesting provider or facility may also attach a narrative of
					 medical necessity and supporting clinical documentation (medical records,
					 progress notes, lab reports, radiology studies, etc.); and
(16) if a requesting provider wants to be
					 called directly about missing information, a place to list a direct telephone
					 number for the requesting provider or facility the issuer can call to ask for
					 additional or missing information if needed to process the request. The phone
					 call can only be considered a peer-to-peer discussion required by §
												19.1710 of this title (relating to
					 Requirements Prior to Issuing an Adverse Determination) if it is a discussion
					 between peers that includes, at a minimum, the clinical basis for the URA's
					 decision and a description of documentation or evidence, if any, that can be
					 submitted by the provider of record that, on appeal, might lead to a different
					 utilization review decision.