| (a) Form requirements. The commissioner adopts by reference
the Prior Authorization Request Form for Health Care Services, to
be accepted and used by an issuer in compliance with subsection (b)
of this section. The form and its instruction sheet are posted on
the TDI website at www.tdi.texas.gov/forms/form10.html; or the form
and its instruction sheet can be requested by mail from the Texas
Department of Insurance, Rate and Form Review Office, MC: LH-MCQA,
P.O. Box 12030, Austin, Texas 78711-2030. The form must be reproduced
without changes. The form provides space for the following information:
(1) the plan issuer's name, telephone number, and facsimile
(fax) number;
(2) the date the request is submitted;
(3) the type of review, whether:
(A) nonurgent; or
(B) urgent. An urgent review should only be requested
for a patient with a life-threatening condition or for a patient who
is currently hospitalized, or to authorize treatment following stabilization
of an emergency condition. A provider or facility may also request
an urgent review to authorize treatment of an acute injury or illness
if the provider determines that the condition is severe or painful
enough to warrant an expedited or urgent review to prevent a serious
deterioration of the patient's condition or health;
(4) the type of request (whether an initial request
or an extension, renewal, or amendment of a previous authorization);
(5) the patient's name, date of birth, sex, contact
telephone number, and identifying insurance information;
(6) the requesting provider's or facility's name, NPI
number, specialty, telephone and fax numbers, contact person's name
and telephone number, and the requesting provider's signature and
date, if required (if a signature is required, a signature stamp may
not be used);
(7) the service provider's or facility's name, NPI
number, specialty, and telephone and fax numbers;
(8) the primary care provider's name and telephone
and fax numbers, if the patient's plan requires the patient to have
a primary care provider and that provider is not the requesting provider;
(9) the planned services or procedures and the associated
CPT, CDT, or HCPCS codes, and the planned start and end dates of the
services or procedures;
(10) the diagnosis description, ICD version number
(if more than one version is allowed by the U.S. Department of Health
and Human Services), and ICD code;
(11) identification of the treatment location (inpatient,
outpatient, provider office, observation, home, day surgery, or other
specified location);
(12) information about the duration and frequency of
treatment sessions for physical, occupational, or speech therapy,
cardiac rehabilitation, mental health, or substance abuse;
(13) if requesting prior authorization for home health
care, information about the requested number of home health visits
and their duration and frequency, and an indication whether a physician's
signed order or a nursing assessment is attached;
(14) if requesting prior authorization for durable
medical equipment, an indication whether a physician's signed order
is attached, a description of requested equipment or supplies with
associated HCPCS codes, duration, and, if the patient is a Medicaid
beneficiary, an indication whether a Title 19 Certification is attached;
(15) a place for the requester to include a brief narrative
of medical necessity or other clinical documentation. A requesting
provider or facility may also attach a narrative of medical necessity
and supporting clinical documentation (medical records, progress notes,
lab reports, radiology studies, etc.); and
(16) if a requesting provider wants to be called directly
about missing information, a place to list a direct telephone number
for the requesting provider or facility the issuer can call to ask
for additional or missing information if needed to process the request.
The phone call can only be considered a peer-to-peer discussion required
by §19.1710 of this title (relating to Requirements Prior to
Issuing an Adverse Determination) if it is a discussion between peers
that includes, at a minimum, the clinical basis for the URA's decision
and a description of documentation or evidence, if any, that can be
submitted by the provider of record that, on appeal, might lead to
a different utilization review decision.
(b) Acceptance and use of the form.
(1) If a provider or facility submits the form to request
prior authorization of a health care service for which the issuer's
plan requires prior authorization, the issuer must accept and use
the form for that purpose. An issuer may also have on its website
another electronic process a provider or facility may use to request
prior authorization of a health care service.
(2) This form may not be used by a provider or facility:
(A) to request an appeal;
(B) to confirm eligibility;
(C) to verify coverage;
(D) to ask whether a service requires prior authorization;
(E) to request prior authorization of a prescription
drug; or
(F) to request a referral to an out of network physician
facility or other health care provider.
(c) Effective date. An issuer must accept a request
for prior authorization of health care services made by a provider
or facility using the form on or after September 1, 2015.
(d) Availability of the form.
(1) A health benefit plan issuer must make the form
available on paper and electronically on its website.
(2) A health benefit plan issuer's agent that manages
or administers health care services benefits must make the form available
on paper and electronically on its website.
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