<<Prev Rule

Texas Administrative Code

Next Rule>>
TITLE 28INSURANCE
PART 1TEXAS DEPARTMENT OF INSURANCE
CHAPTER 19LICENSING AND REGULATION OF INSURANCE PROFESSIONALS
SUBCHAPTER RUTILIZATION REVIEWS FOR HEALTH CARE PROVIDED UNDER A HEALTH BENEFIT PLAN OR HEALTH INSURANCE POLICY
RULE §19.1719Verification for Health Maintenance Organizations and Preferred Provider Benefit Plans

(a) The words and terms defined in Insurance Code Chapter 1301, concerning Preferred Provider Benefit Plans, and Chapter 843, concerning Health Maintenance Organizations, have the same meaning when used in this section, except as otherwise provided by this subchapter, unless the context clearly indicates otherwise. This section applies to:

  (1) HMOs;

  (2) preferred provider benefit plans;

  (3) preferred providers; and

  (4) physicians, doctors, or other health care providers that provide to an enrollee of an HMO or preferred provider benefit plan:

    (A) care related to an emergency or its attendant episode of care as required by state or federal law; or

    (B) specialty or other medical care or health care services at the request of the HMO, preferred provider benefit plan, or a preferred provider because the services are not reasonably available from a preferred provider who is included in the HMO or preferred provider benefit plan's network.

(b) An HMO or preferred provider benefit plan must be able to receive a request for verification of proposed medical care or health care services:

  (1) by telephone call;

  (2) in writing; and

  (3) by other means, including the Internet, as agreed to by the preferred provider and the HMO or preferred provider benefit plan, provided that the agreement may not limit the preferred provider's option to request a verification by telephone call.

(c) An HMO or preferred provider benefit plan must have appropriate personnel reasonably available at a toll-free telephone number under Insurance Code §1301.133. The HMO or preferred provider benefit plan must acknowledge calls not later than:

  (1) for requests relating to post-stabilization care or a life-threatening condition, within one hour after the beginning of the next time period requiring the availability of appropriate personnel at the toll-free telephone number;

  (2) for requests relating to concurrent hospitalization, within 24 hours after the beginning of the next time period requiring the availability of appropriate personnel at the toll-free telephone number; and

  (3) for all other requests, within two calendar days after the beginning of the next time period requiring the availability of appropriate personnel at the toll-free telephone number.

(d) Any request for verification must contain the following information:

  (1) enrollee name;

  (2) enrollee ID number, if included on an identification card issued by the HMO or preferred provider benefit plan;

  (3) enrollee date of birth;

  (4) name of enrollee or subscriber, if included on an identification card issued by the HMO or preferred provider benefit plan;

  (5) enrollee relationship to enrollee or subscriber;

  (6) presumptive diagnosis, if known; otherwise presenting symptoms;

  (7) description of proposed procedures or procedure codes;

  (8) place of service code where services will be provided and, if place of service is other than provider's office or provider's location, name of hospital or facility where proposed service will be provided;

  (9) proposed date of service;

  (10) group number, if included on an identification card issued by the HMO or preferred provider benefit plan;

  (11) if known to the provider, name and contact information of any other carrier, including the name, address, and telephone number; name of enrollee; plan or ID number; group number (if applicable); and group name (if applicable);

  (12) name of provider providing the proposed services; and

  (13) provider's federal tax ID number.

(e) Receipt of a written request or a written response to a request for verification under this section is subject to the provisions of §21.2816 of this title (relating to Date of Receipt).

(f) If necessary to verify proposed medical care or health care services, an HMO or preferred provider benefit plan may, within one day of receipt of a request for verification, request information from the preferred provider in addition to the information provided in the request for verification. An HMO or preferred provider benefit plan may make only one request for additional information from the requesting preferred provider under this section.

(g) A request for information under subsection (f) of this section must:

  (1) be specific to the verification request;

  (2) describe with specificity the clinical and other information to be included in the response;

  (3) be relevant and necessary for the resolution of the request; and

  (4) be for information contained in or in the process of being incorporated into the enrollee's medical or billing record maintained by the preferred provider.

(h) On receipt of a request for verification from a preferred provider, an HMO or preferred provider benefit plan must issue a verification or declination. The HMO or preferred provider benefit plan must issue the verification or declination within the following time periods.

  (1) Except as provided in paragraphs (2) and (3) of this subsection, an HMO or preferred provider benefit plan must provide a verification or declination in response to a request for verification without delay, and as appropriate to the circumstances of the particular request, but not later than five calendar days after the date of receipt of the request for verification. If the request is received outside of the period requiring the availability of appropriate personnel as required in subsection (c) of this section, the determination must be provided within five calendar days from the beginning of the next time period requiring appropriate personnel.

  (2) If the request is related to a concurrent hospitalization, the response must be sent to the preferred provider without delay but not later than 24 hours after the HMO or preferred provider benefit plan received the request for verification. If the request is received outside of the period requiring the availability of appropriate personnel as required in subsection (c) of this section, the determination must be provided within 24 hours from the beginning of the next time period requiring appropriate personnel.

  (3) If the request is related to post-stabilization care or a life-threatening condition, the response must be sent to the preferred provider without delay but not later than one hour after the HMO or preferred provider benefit plan received the request for verification. If the request is received outside of the period requiring the availability of appropriate personnel as required in subsections (c) and (d) of this section, the determination must be provided within one hour from the beginning of the next time period requiring appropriate personnel.

(i) If the request involves services for which preauthorization is required, the HMO or preferred provider benefit plan must implement the procedures set forth in §19.1718 of this title (relating to Preauthorization for Health Maintenance Organizations and Preferred Provider Benefit Plans) and respond regarding the preauthorization request in compliance with that section.

(j) A verification or declination may be delivered via telephone call, in writing, or by other means, including the Internet, as agreed to by the preferred provider and the HMO or preferred provider benefit plan. If a verification or declination is delivered via telephone call, the HMO or preferred provider benefit plan must, within three calendar days of providing a verbal response, provide a written response which must include, at a minimum:

  (1) enrollee name;

  (2) enrollee ID number;

  (3) requesting provider's name;

  (4) hospital or other facility name, if applicable;

  (5) a specific description, including relevant procedure codes, of the services that are verified or declined;

  (6) if the services are verified, the effective period for the verification, which must not be less than 30 calendar days from the date of verification;

  (7) if the services are verified, any applicable deductibles, copayments, or coinsurance for which the enrollee is responsible;

  (8) if the verification is declined, the specific reason for the declination;

  (9) a unique verification number that allows the HMO or preferred provider benefit plan to match the verification and subsequent claims related to the proposed service; and

  (10) a statement that the proposed services are being verified or declined.


Source Note: The provisions of this §19.1719 adopted to be effective February 20, 2013, 38 TexReg 892

Link to Texas Secretary of State Home Page | link to Texas Register home page | link to Texas Administrative Code home page | link to Open Meetings home page