| (a) The words and terms defined in Insurance Code Chapter
1301 and Chapter 843 have the same meaning when used in this section,
except as otherwise provided by this subchapter, unless the context
clearly indicates otherwise.
(b) An HMO or preferred provider benefit plan that
requires preauthorization as a condition of payment to a preferred
provider must comply with the procedures of this section for determinations
of medical necessity, appropriateness, or the experimental or investigational
nature of care for those services the HMO or preferred provider benefit
plan identifies under subsection (c) of this section.
(c) An HMO or preferred provider benefit plan that
uses a preauthorization process for medical care or health care services
must provide to each contracted preferred provider, not later than
the fifth working day after the date a request is made, a list of
medical care and health care services that allows a preferred provider
to determine which services require preauthorization and information
concerning the preauthorization process.
(d) An HMO or preferred provider benefit plan must
issue and transmit a determination indicating whether the proposed
medical or health care services are preauthorized. This determination
must be issued and transmitted once a preauthorization request for
proposed services that require preauthorization is received from a
preferred provider. The HMO or preferred provider benefit plan must
respond to a request for preauthorization within the following time
periods:
(1) For services not included under paragraphs (2)
and (3) of this subsection, a determination must be issued and transmitted
not later than the third calendar day after the date the request is
received by the HMO or preferred provider benefit plan. If the request
is received outside of the period requiring the availability of appropriate
personnel as required in subsections (e) and (f) of this section,
the determination must be issued and transmitted within three calendar
days from the beginning of the next time period requiring appropriate
personnel.
(2) If the proposed medical or health care services
are for concurrent hospitalization care, the HMO or preferred provider
benefit plan must issue and transmit a determination indicating whether
proposed services are preauthorized within 24 hours of receipt of
the request, followed within three working days after the transmittal
of the determination by a letter notifying the enrollee or the individual
acting on behalf of the enrollee and the provider of record of an
adverse determination. If the request for medical or health care services
for concurrent hospitalization care is received outside of the period
requiring the availability of appropriate personnel as required in
subsections (e) and (f) of this section, the determination must be
issued and transmitted within 24 hours from the beginning of the next
time period requiring appropriate personnel.
(3) If the proposed medical care or health care services
involve post-stabilization treatment, or a life-threatening condition
as defined in §19.1703 of this title (relating to Definitions),
the HMO or preferred provider benefit plan must issue and transmit
a determination indicating whether proposed services are preauthorized
within the time appropriate to the circumstances relating to the delivery
of the services and the condition of the enrollee, but in no case
to exceed one hour from receipt of the request. If the request is
received outside of the period requiring the availability of appropriate
personnel as required in subsections (e) and (f) of this section,
the determination must be issued and transmitted within one hour from
the beginning of the next time period requiring appropriate personnel.
The determination must be provided to the provider of record. If the
HMO or preferred provider benefit plan issues an adverse determination
in response to a request for post-stabilization treatment or a request
for treatment involving a life-threatening condition, the HMO or preferred
provider benefit plan must provide to the enrollee or individual acting
on behalf of the enrollee, and the enrollee's provider of record,
the notification required by §19.1717(a) and (b) of this title
(relating to Independent Review of Adverse Determinations).
(e) A preferred provider may request a preauthorization
determination via telephone from the HMO or preferred provider benefit
plan. An HMO or preferred provider benefit plan must have appropriate
personnel as described in §19.1706 of this title (relating to
Requirements and Prohibitions Relating to Personnel) reasonably available
at a toll-free telephone number to provide the determination between
6:00 a.m. and 6:00 p.m., Central Time, Monday through Friday on each
day that is not a legal holiday and between 9:00 a.m. and noon, Central
Time, on Saturday, Sunday, and legal holidays. An HMO or preferred
provider benefit plan must have a telephone system capable of accepting
or recording incoming requests after 6:00 p.m., Central Time, Monday
through Friday and after noon, Central Time, on Saturday, Sunday,
and legal holidays and must acknowledge each of those calls not later
than 24 hours after the call is received. An HMO or preferred provider
benefit plan providing a preauthorization determination under subsection
(d) of this section must, within three calendar days of receipt of
the request, provide a written notification to the preferred provider.
(f) An HMO providing routine vision services or dental
health care services as a single health care service plan is not required
to comply with subsection (e) of this section with respect to those
services. An HMO providing routine vision services or dental health
care services as a single health care service plan must:
(1) have appropriate personnel as described in §19.1706
of this title reasonably available at a toll-free telephone number
to provide the preauthorization determination between 8:00 a.m. and
5:00 p.m., Central Time, Monday through Friday on each day that is
not a legal holiday;
(2) have a telephone system capable of accepting or
recording incoming requests after 5:00 p.m., Central Time, Monday
through Friday and all day on Saturday, Sunday, and legal holidays,
and must acknowledge each of those calls not later than the next working
day after the call is received; and
(3) when providing a preauthorization determination
under subsection (d) of this section, within three calendar days of
receipt of the request, provide a written notification to the preferred
provider.
(g) If an HMO or preferred provider benefit plan has
preauthorized medical care or health care services, the HMO or preferred
provider benefit plan may not deny or reduce payment to the physician
or provider for those services based on medical necessity, appropriateness,
or the experimental or investigational nature of care unless the physician
or provider has materially misrepresented the proposed medical or
health care services or has substantially failed to perform the preauthorized
medical or health care services.
(h) If an HMO or preferred provider benefit plan issues
an adverse determination in response to a request made under subsection
(d) of this section, a notice consistent with the provisions of §19.1709
of this title (relating to Notice of Determinations Made in Utilization
Review) and §19.1710 of this title (relating to Requirements
Prior to Issuing Adverse Determination) must be provided to the enrollee
or an individual acting on behalf of the enrollee, and the enrollee's
provider of record. An enrollee, an individual acting on behalf of
the enrollee, or the enrollee's provider of record may appeal any
adverse determination under §19.1711 of this title (relating
to Written Procedures for Appeal of Adverse Determination).
(i) This section applies to an agent or other person
with whom an HMO or preferred provider benefit plan contracts to perform
utilization review, or to whom the HMO or preferred provider benefit
plan delegates the performance of preauthorization of proposed medical
or health care services. Delegation of preauthorization services does
not limit in any way the HMO or preferred provider benefit plan's
responsibility to comply with all statutory and regulatory requirements.
(j) The provisions in this subsection apply to an HMO
or a preferred provider benefit plan that uses a preauthorization
process for medical or health care services.
(1) An HMO or a preferred provider benefit plan must
make the requirements and information about the preauthorization process
readily accessible to enrollees, physicians, health care providers,
and the general public by posting the requirements and information
on the HMO's or the preferred provider benefit plan's public internet
website.
(2) The preauthorization requirements and information
described by paragraph (1) of this section must:
(A) be posted:
(i) conspicuously in a location on the public internet
website that does not require the user to login or input personal
information to view the information; except as provided by paragraph
(3) or (4) of this subsection;
(ii) in a format that is easily searchable; and
(iii) in a format that uses design and accessibility
standards defined in Section 508 of the U.S. Rehabilitation Act;
(B) except for the screening criteria under subparagraph
(D)(iii) of this paragraph, be written:
(i) using plain language standards, such as the Federal
Plain Language Guidelines found on www.PlainLanguage.gov; and
(ii) in language that aims to reach a 6th to 8th grade
reading level, if the information is for enrollees and the public;
(C) include a detailed description of the preauthorization
process and procedure; and
(D) include an accurate and current list of medical
or health care services for which the HMO or the preferred provider
benefit plan requires preauthorization that includes the following
information specific to each service:
(i) the effective date of the preauthorization requirement;
(ii) a list or description of any supporting documentation
that the HMO or preferred provider benefit plan requires from the
physician or health care provider ordering or requesting the service
to approve a request for that service;
(iii) the applicable screening criteria, which may
include Current Procedural Terminology codes and International Classification
of Diseases codes; and
(iv) statistics regarding the HMO's or the preferred
provider benefit plan's preauthorization approval and denial rates
for the service in the preceding calendar year, including statistics
in the following categories:
(I) physician or health care provider type and specialty,
if any;
(II) indication offered;
(III) reasons for request denial;
(IV) denials overturned on internal appeal;
(V) denials overturned by an independent review organization;
and
(VI) total annual preauthorization requests, approvals,
and denials for the service.
(3) This subsection may not be construed to require
an HMO or a preferred provider benefit plan to provide specific information
that would violate any applicable copyright law or licensing agreement.
To comply with a posting requirement described by paragraph (2) of
this subsection, an HMO or a preferred provider benefit plan may,
instead of making that information publicly available on the HMO's
or the preferred provider benefit plan's public internet website,
supply a summary of the withheld information sufficient to allow a
licensed physician or other health care provider, as applicable for
the specific service, who has sufficient training and experience
related to the service to understand the basis for the HMO's or the
preferred provider benefit plan's medical necessity or appropriateness
determinations.
(4) If a requirement or information described by paragraph
(1) of this subsection is licensed, proprietary, or copyrighted material
that the HMO or the preferred provider benefit plan has received from
a third party with which the HMO or the preferred provider benefit
plan has contracted, to comply with a posting requirement described
by paragraph (2) of this subsection, the HMO or the preferred provider
benefit plan may, instead of making that information publicly available
on the HMO's or the preferred provider benefit plan's public internet
website, provide the material to a physician or health care provider
who submits a preauthorization request using a nonpublic secured internet
website link or other protected, nonpublic electronic means.
(5) The provisions in this paragraph apply when an
HMO or a preferred provider benefit plan makes changes to preauthorization
requirements.
(A) Except as provided by subparagraph (B) of this
paragraph, not later than the 60th day before the date a new or amended
preauthorization requirement takes effect, an HMO or a preferred provider
benefit plan must provide notice of the new or amended preauthorization
requirement and disclose the new or amended requirement in the HMO's
or the preferred provider benefit plan's newsletter or network bulletin,
if any, and on the HMO's or the preferred provider benefit plan's
public internet website.
(B) For a change in a preauthorization requirement
or process that removes a service from the list of medical and health
care services requiring preauthorization or amends a preauthorization
requirement in a way that is less burdensome to enrollees or participating
physicians or health care providers, an HMO or a preferred provider
benefit plan must provide notice of the change in the preauthorization
requirement and disclose the change in the HMO's or the preferred
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