| (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.
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