| (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
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 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
Cont'd... |
