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Rule §21.3101 General Provisions

Published: 2015

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(a) Purpose. The purposes of this subchapter are to:
  (1) ensure that enrollees in health benefit plans receive
coverage for certain services for acquired brain injury and to facilitate
the recovery and progressive rehabilitation of survivors of acquired
brain injuries to the extent possible to their preinjury condition
by making available therapies that are medically necessary, clinically
proven, goal-oriented, efficacious, based on individualized treatment
plans, and provided by, or ordered and provided under, the direction
of a licensed healthcare practitioner with the goal of returning the
individual to, or maintaining the individual in, the most integrated
living environment appropriate to the individual;
  (2) ensure that an issuer provides coverage for services
related to an acquired brain injury under the medical and surgical
provisions of the health benefit plan; and
  (3) require the issuer of a health benefit plan to
provide adequate training of individuals responsible for preauthorization
of coverage or utilization review under the plan in order to prevent
wrongful denial of coverage required under Insurance Code Chapter
1352 and this subchapter, and to avoid confusion of medical and surgical
benefits with mental and behavioral health benefits.