The following words and terms have the following meanings when
used in this subchapter unless the context clearly indicates otherwise.
(1) Adverse determination regarding a preauthorization
exemption--A decision by an issuer that one or more claims retrospectively
reviewed as part of an evaluation as defined in paragraph (4)(B) of
this section, with respect to a particular health care service for
which the physician or provider has a preauthorization exemption,
did not meet the issuer's screening criteria, and leads to an issuer's
decision to rescind a preauthorization exemption. An adverse determination
regarding a preauthorization exemption is not an adverse determination
as defined under §19.1703 of this title (relating to Definitions).
(2) Denial of preauthorization exemption--A determination
that a physician or provider does not qualify for a preauthorization
exemption based on the issuer conducting an evaluation, as defined
in paragraph (4)(A) of this section, of eligible preauthorization
requests and demonstrating that the physician or provider received
approval for fewer than 90% of the eligible preauthorization requests
made for a particular health care service during the most recent evaluation
period.
(3) Eligible preauthorization request--A preauthorization
request for a particular health care service is eligible for the purposes
of an evaluation under paragraph (4)(A) of this section if it is submitted
by the physician or provider and finalized by the health plan during
the evaluation period, is not pending appeal, and has an outcome of
either approving the particular health care service or issuing an
adverse determination for the particular health care service. A preauthorization
request that is modified with the acceptance of the physician or provider
and approved by the plan as modified is an eligible preauthorization
request for the purpose of conducting an evaluation under this section,
with respect to the particular health care service that was approved.
If a preauthorization request includes more than one particular health
care service, the outcome for each service must be counted separately
for the purposes of an evaluation.
(4) Evaluation--
(A) with respect to a particular health care service
for which a physician or provider does not have a preauthorization
exemption, a review of the outcomes of eligible preauthorization requests
submitted by the physician or provider during the most recent evaluation
period to determine the percentage of requests that were approved,
which is conducted for the purpose of evaluating whether to grant
or deny a preauthorization exemption; or
(B) with respect to a particular health care service
for which a physician or provider has a preauthorization exemption,
a retrospective review of a random sample of payable claims submitted
by or in connection with the physician or provider during the most
recent evaluation period to determine the percentage of claims that
would have been approved, based on meeting the issuer's applicable
medical necessity criteria at the time the service was provided, which
is conducted for the purpose of evaluating whether to continue or
rescind a preauthorization exemption and consistent with Insurance
Code §4201.655, concerning Denial or Rescission of Preauthorization
Exemption.
(5) Evaluation period--The six-month period preceding
an evaluation. The evaluation periods are as follows:
(A) for an initial determination of a preauthorization
exemption grant or denial, the evaluation period is the six-month
period that begins on January 1, 2022, or the subsequent six-month
periods of July 1 - December 31 and January 1 - June 30 that follow
each year;
(B) after a denial or rescission of a preauthorization
exemption for a particular health care service, the subsequent six-month
evaluation period begins on the first day following the end of the
evaluation period that formed the basis of the denial or rescission;
and
(C) for a notification of a preauthorization exemption
rescission as provided in Insurance Code §4201.655(a), the evaluation
period is the six-month period an issuer determines or the subsequent
six-month periods that follow, but there may not be more than two
months between an evaluation period ending and the provision of notice
under §19.1732 of this title (relating to Notice of Preauthorization
Exemption Grants, Denials, or Rescissions).
(6) Issuer--A health maintenance organization or insurer
that is subject to Insurance Code Chapter 4201, Subchapter N, including
a URA or a person who contracts with an issuer to issue a preauthorization
determination, or performs the functions described in this division.
(7) Particular health care service--A health care service,
including a prescription drug, that is subject to preauthorization
as listed on the issuer's website under §19.1718(j) of this title
(relating to Preauthorization for Health Maintenance Organizations
and Preferred Provider Benefit Plans).
(8) Physician--Has the meaning assigned by Insurance
Code §843.002, concerning Definitions.
(9) Preauthorization--Has the meaning assigned in Insurance
Code §4201.651, concerning Definitions. "Preauthorization" under
this division does not include concurrent utilization review.
(10) Preauthorization exemption--A privilege obtained
under this division in which a physician or provider is not subject
to a preauthorization requirement that otherwise applies with respect
to a particular health care service. The preauthorization exemption
applies both to care rendered by a treating physician or provider
and to care ordered by a physician or provider who is acting in his
or her capacity as a treating physician or provider.
(11) Provider--Has the meaning assigned by Insurance
Code §843.002.
(12) Random sample--A collection of at least five but
no more than 20 claims for a particular health care service, selected
without method or conscious decision, for the purpose of evaluating
a physician's or provider's continued eligibility for a preauthorization
exemption.
(13) Rescission of preauthorization exemption--An adverse
determination regarding a preauthorization exemption based on an evaluation,
as defined in paragraph (4)(B) of this section and consistent with
Insurance Code §4201.655(b), in which the issuer would have fully
approved fewer than 90% of claims for a particular health care service.
(14) Treating physician or provider--The physician
or other provider who is primarily responsible for a patient's health
and medical care. A "treating physician or provider" can include a
rendering physician or provider or a referring or ordering physician
or provider.
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