| (a) When granting a preauthorization exemption, an
issuer must provide notice to the physician or provider, consistent
with Insurance Code §4201.659(d), concerning Effect of Preauthorization
Exemption. The notice must include a plain language explanation of
the effect of the preauthorization exemption and any claim coding
guidance needed to document the preauthorization exemption, consistent
with §19.1731(e) of this title (relating to Preauthorization
Exemption). The exemption begins on the date the notice is issued
and must be in place for at least six months before it may be rescinded.
If an issuer subsequently receives a preauthorization request from
the physician or provider for a particular health care service for
which an exemption has been granted, the issuer must provide a notice
consistent with Insurance Code §4201.659(e).
(b) When denying a preauthorization exemption, an issuer
must provide notice to the physician or provider that demonstrates
that the physician or provider does not meet the criteria for a preauthorization
exemption, consistent with Insurance Code §4201.655(c)(2), concerning
Denial or Rescission of Preauthorization Exemption; a description
of how to appeal the denial using the issuer's complaints and appeals
processes; and information on how to file a complaint with the department.
(c) After completing an evaluation as defined under §19.1730(4)(A)
of this title (relating to Definitions), an issuer must provide a
notice granting or denying a preauthorization exemption within five
days. For the initial evaluation period of January 1 through June
30, 2022, an issuer must provide notice granting or denying a preauthorization
exemption no later than October 1, 2022. For subsequent evaluation
periods during which a physician or provider does not have a preauthorization
exemption, an issuer must provide notice to the physician or provider
granting or denying a preauthorization exemption no later than two
months following the day after the end of the evaluation period. Notice
need only be provided for a particular health care service if the
issuer was able to complete an evaluation of at least five eligible
preauthorization requests, as provided in §19.1731(b) of this
title.
(d) When rescinding a preauthorization exemption, an
issuer must provide notice to the physician or provider, consistent
with Insurance Code §4201.655(a)(3). Notice of the rescission
must be provided during the months specified in Insurance Code §4201.655(a)(1).
The notice must include the following (a sample form LHL011 is available
on TDI's website):
(1) an identification of the health care service for
which a preauthorization exemption is being rescinded, the date the
notice is issued, and the date the rescission is effective, consistent
with Insurance Code §4201.654, concerning Duration of Preauthorization
Exemption;
(2) a plain language explanation of how the physician
or provider may appeal and seek an independent review of the determination,
the date the notice is issued, and the company's address and contact
information for returning the form by mail or electronic means to
request an appeal;
(3) a statement of the total number of payable claims
submitted by or in connection with the physician or provider during
the most recent evaluation period that were eligible to be evaluated
with respect to the health care service subject to rescission, the
number of claims included in the random sample, and the sample information
used to make the determination, including:
(A) identification of each claim included in the random
sample;
(B) the issuer's determination of whether each claim
met the issuer's screening criteria; and
(C) for any claim determined to not have met the issuer's
screening criteria:
(i) the principal reasons for the determination that
the claim did not meet the issuer's screening criteria, including,
if applicable, a statement that the determination was based on a failure
to submit specified medical records;
(ii) the clinical basis for the determination that
the claim did not meet the issuer's screening criteria;
(iii) a description of the sources of the screening
criteria that were used as guidelines in making the determination;
and
(iv) the professional specialty of the physician, doctor,
or other health care provider who made the determination;
(4) a space to be filled out by the physician or provider
that includes:
(A) the name, address, contact information, and identification
number of the physician or provider requesting an independent review;
(B) an indication of whether the physician or provider
is requesting that the independent review organization review the
same random sample or a different random sample of claims, if available;
and
(C) the date the appeal is being requested; and
(5) an instruction for the physician or provider to
return the form to the issuer before the date the rescission becomes
effective and to include applicable medical records for any determination
that was based on a failure to provide medical records.
(e) An issuer must allow physicians and providers to
designate an email address or a mailing address for communications
regarding preauthorization exemptions, denials, and rescissions. An
issuer must provide an option for physicians and providers to submit
a request for appeal by mail or by email or other electronic method.
Issuers must include an explanation of how the physician or provider
may update their preferred contact information and delivery method
on all communications issued under this section and on the website
required under §19.1718(j) of this title (relating to Preauthorization
for Health Maintenance Organizations and Preferred Provider Benefit
Plans).
|
