(a) The words and terms defined in Insurance Code Chapter
1301, concerning Preferred Provider Benefit Plans, and Chapter 843,
concerning Health Maintenance Organizations, have the same meaning
when used in this section, except as otherwise provided by this subchapter,
unless the context clearly indicates otherwise. This section applies
to:
(1) HMOs;
(2) preferred provider benefit plans;
(3) preferred providers; and
(4) physicians, doctors, or other health care providers
that provide to an enrollee of an HMO or preferred provider benefit
plan:
(A) care related to an emergency or its attendant episode
of care as required by state or federal law; or
(B) specialty or other medical care or health care
services at the request of the HMO, preferred provider benefit plan,
or a preferred provider because the services are not reasonably available
from a preferred provider who is included in the HMO or preferred
provider benefit plan's network.
(b) An HMO or preferred provider benefit plan must
be able to receive a request for verification of proposed medical
care or health care services:
(1) by telephone call;
(2) in writing; and
(3) by other means, including the Internet, as agreed
to by the preferred provider and the HMO or preferred provider benefit
plan, provided that the agreement may not limit the preferred provider's
option to request a verification by telephone call.
(c) An HMO or preferred provider benefit plan must
have appropriate personnel reasonably available at a toll-free telephone
number under Insurance Code §1301.133. The HMO or preferred provider
benefit plan must acknowledge calls not later than:
(1) for requests relating to post-stabilization care
or a life-threatening condition, within one hour after the beginning
of the next time period requiring the availability of appropriate
personnel at the toll-free telephone number;
(2) for requests relating to concurrent hospitalization,
within 24 hours after the beginning of the next time period requiring
the availability of appropriate personnel at the toll-free telephone
number; and
(3) for all other requests, within two calendar days
after the beginning of the next time period requiring the availability
of appropriate personnel at the toll-free telephone number.
(d) Any request for verification must contain the following
information:
(1) enrollee name;
(2) enrollee ID number, if included on an identification
card issued by the HMO or preferred provider benefit plan;
(3) enrollee date of birth;
(4) name of enrollee or subscriber, if included on
an identification card issued by the HMO or preferred provider benefit
plan;
(5) enrollee relationship to enrollee or subscriber;
(6) presumptive diagnosis, if known; otherwise presenting
symptoms;
(7) description of proposed procedures or procedure
codes;
(8) place of service code where services will be provided
and, if place of service is other than provider's office or provider's
location, name of hospital or facility where proposed service will
be provided;
(9) proposed date of service;
(10) group number, if included on an identification
card issued by the HMO or preferred provider benefit plan;
(11) if known to the provider, name and contact information
of any other carrier, including the name, address, and telephone
number; name of enrollee; plan or ID number; group number (if applicable);
and group name (if applicable);
(12) name of provider providing the proposed services;
and
(13) provider's federal tax ID number.
(e) Receipt of a written request or a written response
to a request for verification under this section is subject to the
provisions of §21.2816 of this title (relating to Date of Receipt).
(f) If necessary to verify proposed medical care or
health care services, an HMO or preferred provider benefit plan may,
within one day of receipt of a request for verification, request information
from the preferred provider in addition to the information provided
in the request for verification. An HMO or preferred provider benefit
plan may make only one request for additional information from the
requesting preferred provider under this section.
(g) A request for information under subsection (f)
of this section must:
(1) be specific to the verification request;
(2) describe with specificity the clinical and other
information to be included in the response;
(3) be relevant and necessary for the resolution of
the request; and
(4) be for information contained in or in the process
of being incorporated into the enrollee's medical or billing record
maintained by the preferred provider.
(h) On receipt of a request for verification from a
preferred provider, an HMO or preferred provider benefit plan must
issue a verification or declination. The HMO or preferred provider
benefit plan must issue the verification or declination within the
following time periods.
(1) Except as provided in paragraphs (2) and (3) of
this subsection, an HMO or preferred provider benefit plan must provide
a verification or declination in response to a request for verification
without delay, and as appropriate to the circumstances of the particular
request, but not later than five calendar days after the date of receipt
of the request for verification. If the request is received outside
of the period requiring the availability of appropriate personnel
as required in subsection (c) of this section, the determination must
be provided within five calendar days from the beginning of the next
time period requiring appropriate personnel.
(2) If the request is related to a concurrent hospitalization,
the response must be sent to the preferred provider without delay
but not later than 24 hours after the HMO or preferred provider benefit
plan received the request for verification. If the request is received
outside of the period requiring the availability of appropriate personnel
as required in subsection (c) of this section, the determination must
be provided within 24 hours from the beginning of the next time period
requiring appropriate personnel.
(3) If the request is related to post-stabilization
care or a life-threatening condition, the response must be sent to
the preferred provider without delay but not later than one hour after
the HMO or preferred provider benefit plan received the request for
verification. If the request is received outside of the period requiring
the availability of appropriate personnel as required in subsections
(c) and (d) of this section, the determination must be provided within
one hour from the beginning of the next time period requiring appropriate
personnel.
(i) If the request involves services for which preauthorization
is required, the HMO or preferred provider benefit plan must implement
the procedures set forth in §19.1718 of this title (relating
to Preauthorization for Health Maintenance Organizations and Preferred
Provider Benefit Plans) and respond regarding the preauthorization
request in compliance with that section.
(j) A verification or declination may be delivered
via telephone call, in writing, or by other means, including the Internet,
as agreed to by the preferred provider and the HMO or preferred provider
benefit plan. If a verification or declination is delivered via telephone
call, the HMO or preferred provider benefit plan must, within three
calendar days of providing a verbal response, provide a written response
which must include, at a minimum:
(1) enrollee name;
(2) enrollee ID number;
(3) requesting provider's name;
(4) hospital or other facility name, if applicable;
(5) a specific description, including relevant procedure
codes, of the services that are verified or declined;
(6) if the services are verified, the effective period
for the verification, which must not be less than 30 calendar days
from the date of verification;
(7) if the services are verified, any applicable deductibles,
copayments, or coinsurance for which the enrollee is responsible;
(8) if the verification is declined, the specific reason
for the declination;
(9) a unique verification number that allows the HMO
or preferred provider benefit plan to match the verification and
subsequent claims related to the proposed service; and
(10) a statement that the proposed services are being
verified or declined.
|