| (a) For a retrospective review that is conducted under
Insurance Code §4201.659(b)(1), concerning Effect of Preauthorization
Exemption, to determine whether the physician or provider still qualifies
for an exemption, Insurance Code §4201.305, concerning Notice
of Adverse Determination for Retrospective Utilization Review, does
not apply.
(b) An issuer that is conducting an evaluation as defined
in §19.1730(4)(B) of this title (relating to Definitions) to
determine whether a physician or provider still qualifies for a preauthorization
exemption may request medical records or other documents, consistent
with §19.1707 of this title (relating to URA Contact with and
Receipt of Information from Health Care Providers), and must provide
at least 30 days for a physician or provider to provide the records.
Medical records requested in connection with a retrospective review
of a random sample of claims as authorized under Insurance Code §4201.659(b)(1)
should be limited to no more than 20 claims for a particular health
care service and may be requested only during an evaluation period
or within 90 days following the end of an evaluation period. If the
physician or provider fails to provide the records necessary for the
issuer to make a determination, the issuer may determine that the
claim would not have met the screening criteria.
(c) After receiving a notice of rescission, a physician
or provider may request an independent review of the adverse determination
regarding a preauthorization exemption at any time before the rescission
becomes effective. The date of the request must be documented on the
form, and the form must be sent electronically or postmarked before
the date the rescission becomes effective.
(d) In order to request an independent review of a
rescission of a preauthorization exemption, a physician or provider
must submit the form provided by the issuer under §19.1732(c)
of this title (relating to Notice of Preauthorization Exemption Grants,
Denials, or Rescissions). If one or more determinations subject to
review were based on a failure to provide specified medical records,
the physician or provider must include the applicable records with
the request for an independent review. Upon receipt, if the issuer
seeks to proceed with the proposed rescission, the issuer must submit
the request for independent review to the department, consistent with §12.601
of this title (relating to Preauthorization Exemptions), and §19.1717(c)
of this title (relating to Independent Review of Adverse Determinations),
and provide information to the IRO consistent with Insurance Code §4201.402.
(e) If the notice of rescission of preauthorization
exemption identified that at least five additional claims were eligible
for review but not included in the original random sample, the physician
or provider may request review of another random sample of claims,
as authorized under Insurance Code §4201.656(d). If this request
is made, the issuer must, when submitting the request for independent
review to the department, provide a listing of all payable claims
for the same health care service submitted by or in connection with
the physician or provider during the most recent evaluation period
that were eligible to be evaluated but that were not included in the
original random sample. The listing must be sufficiently detailed
to allow the IRO to identify each payable claim to be used in an additional
random sample, as provided by §12.601(e) of this title.
(f) An issuer must communicate the determination of
a review by an independent review organization under §12.601
of this title to the physician or provider within five days.
(g) In order to retain a preauthorization exemption,
a physician or provider must continue to maintain medical records
adequate to demonstrate that health care services meet medical guidelines.
In the absence of adequate records during an evaluation or appeal,
an exemption may be rescinded.
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