| (a) In this section, "preauthorization" has the meaning
assigned by Insurance Code §1352.004(a), and includes benefit
determinations for proposed medical or health care services.
(b) Each issuer must develop written preauthorization
and utilization review policies and procedures for the purpose of
identifying services to be covered for acquired brain injury, to be
used by any individual responsible for preauthorization of coverage
or utilization review. Such policies and procedures must include:
(1) identification of all current Common Procedural
Terminology (CPT) codes associated with services for acquired brain
injury; and
(2) a means to identify an enrollee initially diagnosed
with an acquired brain injury.
(c) Each health benefit plan issuer must ensure that
all employees or staff responsible for preauthorization of coverage
or utilization review, or any individual performing these processes,
receive training to prevent wrongful denial of coverage required under
Insurance Code Chapter 1352 and this subchapter, and to avoid confusion
of medical and surgical benefits with mental and behavioral health
benefits. At a minimum, training must consist of:
(1) identification of services likely to be requested
in treating an enrollee with an acquired brain injury;
(2) identification of specific therapies currently
used in treating an enrollee with an acquired brain injury;
(3) instruction relating to correctly evaluating requests
for services to differentiate between covered medical and surgical
benefits versus covered benefits for mental and behavioral health;
and
(4) instruction relating to the requirements of Insurance
Code Chapter 1352 and this subchapter.
(d) At a minimum, training must be accomplished by
attendance at an initial orientation, in-service, or continuing education
program relating to acquired brain injuries and their treatments,
provided that the training is consistent with the requirements of
subsections (a) and (b) of this section.
(1) Documentation and verification of training must
be maintained for each employee or staff member responsible for preauthorization
of coverage, utilization review, or any individual performing these
processes.
(2) On request, any documentation and verification
required by paragraph (1) of this subsection must be provided to the
issuer with whom the employee, staff member, or individual is employed
or contracted.
(3) On request, any documentation and verification
required by paragraph (1) of this subsection must be provided to the
department for review.
(e) The requirements of this section also apply to
any contracted entity of an issuer to the extent the contracted entity
is responsible for preauthorization or utilization review.
|
| Source Note: The provisions of this §21.3104 adopted to be effective August 26, 2002, 27 TexReg 7814; amended to be effective February 23, 2009, 34 TexReg 1247; amended to be effective June 7, 2015, 40 TexReg 3179 |
