| benefit plan's newsletter or network bulletin, if any, and
on the HMO's or the preferred provider benefit plan's public internet
website not later than the fifth day before the date the change takes
effect.
(C) Not later than the fifth day before the date a
new or amended preauthorization requirement takes effect, an HMO or
a preferred provider benefit plan must update its public internet
website to disclose the change to the HMO's or the preferred provider
benefit plan's preauthorization requirements or process and the date
and time the change is effective.
(6) In addition to any other penalty or remedy provided
by law, an HMO or a preferred provider benefit plan that uses a preauthorization
process for medical or health care services that violates this section
with respect to a required publication, notice, or response regarding
its preauthorization requirements, including by failing to comply
with any applicable deadline for the publication, notice, or response,
must provide an expedited appeal under Insurance Code §4201.357
for any health care service affected by the violation. This paragraph
does not apply to subsections (f), (k), and (l) of this section.
(7) The provisions of this subsection may not be waived,
voided, or nullified by contract.
(k) The provisions of this subsection apply to dental
care services under an employee benefit plan or health insurance policy
that require prior authorization.
(1) In this subsection, the definitions in Texas Insurance
Code §1451.201 for "dental care service," "employee benefit plan,"
and "health insurance policy" apply.
(2) In this subsection, "prior authorization" means
a written and verifiable determination that one or more specific dental
care services are covered under the patient's employee benefit plan
or health insurance policy and are payable and reimbursable in a specific
stated amount, subject to applicable coinsurance and deductible amounts.
The term includes preauthorization and similar authorization. The
term does not include predetermination as that term is defined by
Insurance Code §1451.207(c).
(3) For services for which a prior authorization is
required, on request of a patient or treating dentist, an employee
benefit plan or health insurance policy provider or issuer must provide
to the dentist a written prior authorization of benefits for a dental
care service for the patient. The prior authorization must include
a specific benefit payment or reimbursement amount. Except as provided
by paragraph (4) of this subsection, the plan or policy provider or
issuer may not pay or reimburse the dentist in an amount that is less
than the amount stated in the prior authorization.
(4) An employee benefit plan or health insurance policy
provider or issuer that preauthorizes a dental care service under
paragraph (3) of this subsection may deny a claim for the dental care
service or reduce payment or reimbursement to the dentist for the
service only if:
(A) the denial or reduction is in accordance with the
patient's employee benefit plan or health insurance policy benefit
limitations, including an annual maximum or frequency of treatment
limitation, and the patient met the benefit limitation after the date
the prior authorization was issued;
(B) the documentation for the claim fails to reasonably
support the claim as preauthorized;
(C) the preauthorized dental service was not medically
necessary based on the prevailing standard of care on the date of
the service, or is subject to denial under the conditions for coverage
under the patient's plan or policy in effect at the time the service
was preauthorized, because of a change in the patient's condition
or because the patient received additional dental care after the date
the prior authorization was issued;
(D) a payor other than the employee benefit plan or
health insurance policy provider or issuer is responsible for payment
of the claim;
(E) the dentist received full payment for the preauthorized
dental care service on which the claim is based;
(F) the claim is fraudulent;
(G) the prior authorization was based wholly or partly
on a material error in information provided to the employee benefit
plan or health insurance policy provider or issuer by any person not
related to the provider or the issuer; or
(H) the patient was otherwise ineligible for the dental
care service under the patient's employee benefit plan or health insurance
policy and the plan or policy issuer did not know, and could not reasonably
have known, that the patient was ineligible for the dental care service
on the date the prior authorization was issued.
(l) If a health benefit plan issuer subject to Insurance
Code Chapter 1222 requires preauthorization as a condition of payment
for a medical or health care service, the heath benefit plan issuer
must provide a preauthorization renewal process that allows a physician
or health care provider to request renewal of an existing preauthorization
at least 60 days before the date the preauthorization expires. When
practicable, a URA must review and issue a determination on a renewal
request before the existing preauthorization expires if the URA receives
the request before the existing preauthorization expires. The determination
must indicate whether the medical or health care service is preauthorized.
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