| (a) In this section, the following words and terms
have the following meanings unless context clearly indicates otherwise.
(1) Adverse determination regarding a preauthorization
exemption--Has the same meaning as defined in §19.1730 of this
title (relating to Definitions).
(2) Issuer--Has the same meaning as defined in §19.1730
of this title.
(3) Physician--Has the same meaning as defined by Insurance
Code §843.002, concerning Definitions.
(4) Preauthorization exemption--Has the same meaning
as defined in §19.1730 of this title.
(5) Provider--Has the same meaning as defined in Insurance
Code §843.002.
(b) An independent review of an adverse determination
regarding a preauthorization exemption, the independent review organization
(IRO) that performs the review, and the appropriate issuer are subject
to Insurance Code Chapter 4201, Subchapter N, concerning Exemption
from Preauthorization Requirements for Physicians and Providers Providing
Certain Health Care Services, and the associated standards and requirements
in this chapter, except as otherwise specified in this section.
(c) For purposes of this section, a physician or provider
should be identified using the National Provider Identifier under
which a physician or provider makes preauthorization requests.
(d) Notwithstanding §12.501 of this title (relating
to Requests for Independent Review), an issuer must submit a request
for independent review of an adverse determination regarding a preauthorization
exemption to the department on behalf of a physician or provider.
(e) If a second random sample is requested under Insurance
Code §4201.656(d), concerning Independent Review of Exemption
Determination, and available as provided in §19.1733(e) of this
title (relating to Retrospective Reviews and Appeals of Preauthorization
Exemption Rescissions), the IRO must identify, from the list of eligible
claims provided by the issuer, a second random sample of at least
five and no more than 20 claims. The IRO must review each claim that
the issuer retrospectively reviewed and determined did not meet the
applicable medical necessity criteria and, if applicable, each claim
included in the second random sample identified by the IRO. Consistent
with Insurance Code §4201.656(b), the IRO may request any medical
records needed to evaluate the claims subject to review and must provide
at least three business days for receipt of records. Based on the
total number of claims in the initial random sample and, if applicable,
the second random sample, the IRO must determine whether to affirm
or overturn the issuer's determination that less than 90 percent of
the claims met the applicable medical necessity criteria.
(f) Appeals for an adverse determination regarding
a preauthorization exemption to an IRO follow the department's process
for assigning IROs under §12.502 of this title (relating to
Random Assignment), except that notification under §12.502(a)
will only be made to the IRO, the issuer, and the physician or provider.
(g) Section 12.206 of this title (relating to Notice
of Determinations Made by Independent Review Organizations) does not
apply to a review by an IRO under this section. An IRO must complete
its review and provide timely notice to an issuer regarding its determination,
consistent with the timeframe provided under Insurance Code §4201.656(c).
|
