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 19.1731 - Preauthorization Exemption

Current through Reg. 49, No. 28; July 12, 2024
(a) For the
					 purposes of this division, a physician or provider should be identified using
					 the National Provider Identifier (NPI) under which a physician or provider
					 makes preauthorization requests.
(b) With respect to a particular health care
					 service for which a physician or provider does not have a preauthorization
					 exemption, an issuer must conduct an evaluation of all preauthorization
					 requests submitted by the physician or provider during the most recent
					 evaluation period that were finalized prior to the evaluation and may not
					 include a request that is pending appeal at the time the data is analyzed. The
					 evaluation must be based on no fewer than five eligible preauthorization
					 requests.
(c) With respect to a
					 particular health care service for which a physician or provider has a
					 preauthorization exemption, an issuer may conduct an evaluation, as defined in
					 § 19.1730(4)(B) of this title (relating to Definitions), to determine
					 whether to rescind a preauthorization exemption consistent with Insurance Code
					 § 4201.655, concerning Denial or Rescission of Preauthorization Exemption.
					 In order to determine whether to rescind an exemption, the issuer must conduct
					 a retrospective review of a random sample of at least five and no more than 20
					 claims submitted during the most recent evaluation period.
(d) Other than care ordered by a treating
					 physician or provider that has a preauthorization exemption that is then
					 rendered by a physician or provider that does not have an exemption, a treating
					 physician or provider may not rely on another physician's or provider's
					 preauthorization exemption. If a treating physician or provider does not have a
					 preauthorization exemption and relies on another physician's or provider's
					 preauthorization exemption in violation of this subsection, an issuer may
					 consider the physician or provider who has qualified for the preauthorization
					 exemption as failing to substantially perform the health care service under
					 Insurance Code § 4201.659, concerning Effect of Preauthorization
					 Exemption, and may reduce or deny payment for that service on that basis. It is
					 not a violation of this subsection for a provider, such as a nurse or
					 physician's assistant, who practices under the supervision of a physician, to
					 rely on the supervising physician's exemption, if the provider appropriately
					 orders care and requests preauthorization under the supervising physician's
					 NPI.
(e) For care ordered by a
					 treating physician or provider that has a preauthorization exemption that is
					 then rendered by a physician or provider that does not have an exemption, the
					 treating physician or provider must include the name and NPI of the ordering
					 physician or provider on the claim in fields 17 and 17B of CMS Form 1500, in
					 fields 76 - 79 or another appropriate field in Form UB-04, or in the
					 corresponding fields for electronic claims using the ASC X12N 837 format. The
					 issuer may provide coding guidance to physicians and providers to ensure that
					 this information is appropriately captured on the claim. If this information is
					 not included, the issuer may treat the claim as subject to an otherwise
					 applicable preauthorization requirement.