(a) The words and terms defined in Insurance Code Chapter
1301 and Chapter 843 have the same meaning when used in this section,
except as otherwise provided by this subchapter, unless the context
clearly indicates otherwise.
(b) An HMO or preferred provider benefit plan that
requires preauthorization as a condition of payment to a preferred
provider must comply with the procedures of this section for determinations
of medical necessity or appropriateness, or the experimental or investigational
nature, of care for those services the HMO or preferred provider benefit
plan identifies under subsection (c) of this section.
(c) An HMO or preferred provider benefit plan that
uses a preauthorization process for medical care and health care services
must provide to each contracted preferred provider, not later than
the 10th working day after the date a request is made, a list of medical
care and health care services that allows a preferred provider to
determine which services require preauthorization and information
concerning the preauthorization process.
(d) An HMO or preferred provider benefit plan must
issue and transmit a determination indicating whether the proposed
medical or health care services are preauthorized. This determination
must be issued and transmitted once a preauthorization request for
proposed services that require preauthorization is received from a
preferred provider. The HMO or preferred provider benefit plan must
respond to a request for preauthorization within the following time
periods:
  (1) For services not included under paragraphs (2)
and (3) of this subsection, a determination must be issued and transmitted
not later than the third calendar day after the date the request is
received by the HMO or preferred provider benefit plan. If the request
is received outside of the period requiring the availability of appropriate
personnel as required in subsections (e) and (f) of this section,
the determination must be issued and transmitted within three calendar
days from the beginning of the next time period requiring appropriate
personnel.
  (2) If the proposed medical or health care services
are for concurrent hospitalization care, the HMO or preferred provider
benefit plan must issue and transmit a determination indicating whether
proposed services are preauthorized within 24 hours of receipt of
the request, followed within three working days after the transmittal
of the determination by a letter notifying the enrollee or the individual
acting on behalf of the enrollee and the provider of record of an
adverse determination. If the request for medical or health care services
for concurrent hospitalization care is received outside of the period
requiring the availability of appropriate personnel as required in
subsections (e) and (f) of this section, the determination must be
issued and transmitted within 24 hours from the beginning of the next
time period requiring appropriate personnel.
  (3) If the proposed medical care or health care services
involve post-stabilization treatment, or a life-threatening condition
as defined in §19.1703 of this title (relating to Definitions),
the HMO or preferred provider benefit plan must issue and transmit
a determination indicating whether proposed services are preauthorized
within the time appropriate to the circumstances relating to the delivery
of the services and the condition of the enrollee, but in no case
to exceed one hour from receipt of the request. If the request is
received outside of the period requiring the availability of appropriate
personnel as required in subsections (e) and (f) of this section,
the determination must be issued and transmitted within one hour from
the beginning of the next time period requiring appropriate personnel.
The determination must be provided to the provider of record. If the
HMO or preferred provider benefit plan issues an adverse determination
in response to a request for post-stabilization treatment or a request
for treatment involving a life-threatening condition, the HMO or preferred
provider benefit plan must provide to the enrollee or individual acting
on behalf of the enrollee, and the enrollee's provider of record,
the notification required by §19.1717(a) and (b) of this title
(relating to Independent Review of Adverse Determinations).
(e) A preferred provider may request a preauthorization
determination via telephone from the HMO or preferred provider benefit
plan. An HMO or preferred provider benefit plan must have appropriate
personnel as described in §19.1706 of this title (relating to
Requirements and Prohibitions Relating to Personnel) reasonably available
at a toll-free telephone number to provide the determination between
6:00 a.m. and 6:00 p.m., Central Time, Monday through Friday on each
day that is not a legal holiday and between 9:00 a.m. and noon, Central
Time, on Saturday, Sunday, and legal holidays. An HMO or preferred
provider benefit plan must have a telephone system capable of accepting
or recording incoming requests after 6:00 p.m., Central Time, Monday
through Friday and after noon, Central Time, on Saturday, Sunday,
and legal holidays and must acknowledge each of those calls not later
than 24 hours after the call is received. An HMO or preferred provider
benefit plan providing a preauthorization determination under subsection
(d) of this section must, within three calendar days of receipt of
the request, provide a written notification to the preferred provider.
(f) An HMO providing routine vision services or dental
health care services as a single health care service plan is not required
to comply with subsection (e) of this section with respect to those
services. An HMO providing routine vision services or dental health
care services as a single health care service plan must:
  (1) have appropriate personnel as described in §19.1706
of this title reasonably available at a toll-free telephone number
to provide the preauthorization determination between 8:00 a.m. and
5:00 p.m., Central Time, Monday through Friday on each day that is
not a legal holiday;
  (2) have a telephone system capable of accepting or
recording incoming requests after 5:00 p.m., Central Time, Monday
through Friday and all day on Saturday, Sunday, and legal holidays,
and must acknowledge each of those calls not later than the next working
day after the call is received; and
  (3) when providing a preauthorization determination
under subsection (d) of this section, within three calendar days of
receipt of the request, provide a written notification to the preferred
provider.
(g) If an HMO or preferred provider benefit plan has
preauthorized medical care or health care services, the HMO or preferred
provider benefit plan may not deny or reduce payment to the physician
or provider for those services based on medical necessity or appropriateness,
or the experimental or investigational nature, of care unless the
physician or provider has materially misrepresented the proposed medical
or health care services or has substantially failed to perform the
preauthorized medical or health care services.
(h) If an HMO or preferred provider benefit plan issues
an adverse determination in response to a request made under subsection
(d) of this section, a notice consistent with the provisions of §19.1709
of this title (relating to Notice of Determinations Made in Utilization
Review) and §19.1710 of this title (relating to Requirements
Prior to Issuing Adverse Determination) must be provided to the enrollee
or an individual acting on behalf of the enrollee, and the enrollee's
provider of record. An enrollee, an individual acting on behalf of
the enrollee, or the enrollee's provider of record may appeal any
adverse determination under §19.1711 of this title (relating
to Written Procedures for Appeal of Adverse Determination).
(i) This section applies to an agent or other person
with whom an HMO or preferred provider benefit plan contracts to perform
utilization review, or to whom the HMO or preferred provider benefit
plan delegates the performance of preauthorization of proposed medical
or health care services. Delegation of preauthorization services does
not limit in any way the HMO or preferred provider benefit plan's
responsibility to comply with all statutory and regulatory requirements.



Source Note: The provisions of this §19.1718 adopted to be effective February 20, 2013, 38 TexReg 892