See bold sections below

Section 19.1703. Definitions

(a) The words and terms defined in Insurance Code Chapter 4201 have the same meaning when used in this subchapter, except as otherwise provided by this subchapter, unless the context clearly indicates otherwise.

(b) The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise.

(1) Adverse determination–A determination by a URA made on behalf of any payor that the health care services provided or proposed to be provided to an enrollee are not medically necessary or appropriate or are experimental or investigational. The term does not include a denial of health care services due to the failure to request prospective or concurrent utilization review.

(2) Appeal–A URA’s formal process by which an enrollee, an individual acting on behalf of an enrollee, or an enrollee’s provider of record may request reconsideration of an adverse determination.

(3) Biographical affidavit–National Association of Insurance Commissioners biographical affidavit to be used as an attachment to the URA application.

(4) Certificate–A certificate issued by the commissioner to an entity authorizing the entity to operate as a URA in the State of Texas. A certificate is not issued to an insurance carrier or health maintenance organization that is registered as a URA under §19.1704 of this title (relating to Certification or Registration of URAs).

(5) Commissioner–As defined in Insurance Code §31.001.

(6) Complaint–An oral or written expression of dissatisfaction with a URA concerning the URA’s process in conducting a utilization review. The term “complaint” does not include:

(A) an expression of dissatisfaction constituting an appeal under Insurance Code §4201.351; or

(B) a misunderstanding or misinformation that is resolved promptly by supplying the appropriate information or by clearing up the misunderstanding to the satisfaction of the complaining party.

(7) Concurrent utilization review–A form of utilization review for ongoing health care or for an extension of treatment beyond previously approved health care.

(8) Declination–A response to a request for verification in which an HMO or preferred provider benefit plan does not issue a verification for proposed medical care or health care services. A declination is not necessarily a determination that a claim resulting from the proposed services will not ultimately be paid.

(9) Disqualifying association–Any association that may reasonably be perceived as having potential to influence the conduct or decision of a reviewing physician, doctor, or other health care provider, which may include:

(A) shared investment or ownership interest;

(B) contracts or agreements that provide incentives, for example, referral fees, payments based on volume or value, or waiver of beneficiary coinsurance and deductible amounts;

(C) contracts or agreements for space or equipment rentals, personnel services, management contracts, referral services, warranties, or any other services related to the management of a physician’s, doctor’s, or other health care provider’s practice;

(D) personal or family relationships; or

(E) any other financial arrangement that would require disclosure under the Insurance Code or applicable TDI rules, or any other association with the enrollee, employer, insurance carrier, or HMO that may give the appearance of preventing the reviewing physician, doctor, or other health care provider from rendering an unbiased opinion.

(10) Doctor–A doctor of medicine, osteopathic medicine, optometry, dentistry, podiatry, or chiropractic who is licensed and authorized to practice.

(11) Experimental or investigational–A health care treatment, service, or device for which there is early, developing scientific or clinical evidence demonstrating the potential efficacy of the treatment, service, or device, but that is not yet broadly accepted as the prevailing standard of care.

(12) Health care facility–A hospital, emergency clinic, outpatient clinic, or other facility providing health care.

(13) Health coverage–Payment for health care services provided under a health benefit plan or a health insurance policy.

(14) Health maintenance organization or HMO–As defined in Insurance Code §843.002.

(15) Insurance carrier or insurer–An entity authorized and admitted to do the business of insurance in Texas under a certificate of authority issued by TDI.

(16) Independent review organization or IRO–As defined in §12.5 of this title (relating to Definitions).

(17) Legal holiday–

(A) a holiday as provided in Government Code §662.003(a);

(B) the Friday after Thanksgiving Day;

(C) December 24; and

(D) December 26.

(18) Medical records–The history of diagnosis and treatment, including medical, mental health records as allowed by law, dental, and other health care records from all disciplines providing care to an enrollee.

(19) Mental health medical record summary–A summary of process or progress notes relevant to understanding the enrollee’s need for treatment of a mental or emotional condition or disorder, including:

(A) identifying information; and

(B) a treatment plan that includes a:

(i) diagnosis;

(ii) treatment intervention;

(iii) general characterization of enrollee behaviors or thought processes that affect level of care needs; and

(iv) discharge plan.

(20) Mental health therapist–Any of the following individuals who, in the ordinary course of business or professional practice, as appropriate, diagnose, evaluate, or treat any mental or emotional condition or disorder:

(A) an individual licensed by the Texas Medical Board to practice medicine in this state;

(B) an individual licensed as a psychologist, a psychological associate, or a specialist in school psychology by the Texas State Board of Examiners of Psychologists;

(C) an individual licensed as a marriage and family therapist by the Texas State Board of Examiners of Marriage and Family Therapists;

(D) an individual licensed as a professional counselor by the Texas State Board of Examiners of Professional Counselors;

(E) an individual licensed as a social worker by the Texas State Board of Social Worker Examiners;

(F) an individual licensed as a physician assistant by the Texas Medical Board;

(G) an individual licensed as a registered professional nurse by the Texas Board of Nursing; or

(H) any other individual who is licensed or certified by a state licensing board in the State of Texas, as appropriate, to diagnose, evaluate, or treat any mental or emotional condition or disorder.

(21) Mental or emotional condition or disorder–A mental or emotional illness as detailed in the most current Diagnostic and Statistical Manual of Mental Disorders.

(22) Person–Any individual, partnership, association, corporation, organization, trust, hospital district, community mental health center, mental retardation center, mental health and mental retardation center, limited liability company, limited liability partnership, the statewide rural health care system under Insurance Code Chapter 845, and any similar entity.

(23) Preauthorization–A form of prospective utilization review by a payor or its URA of health care services proposed to be provided to an enrollee.

(24) Preferred provider–

(A) with regard to a preferred provider benefit plan, a preferred provider as defined in Insurance Code Chapter 1301.

(B) with regard to an HMO:

(i) a physician, as defined in Insurance Code §843.002(22), who is a member of that HMO’s delivery network; or

(ii) a provider, as defined in Insurance Code §843.002(24), who is a member of that HMO’s delivery network.

(25) Provider of record–The physician, doctor, or other health care provider that has primary responsibility for the health care services rendered or requested on behalf of the enrollee or the physician, doctor, or other health care provider that has rendered or has been requested to provide the health care services to the enrollee. This definition includes any health care facility where health care services are rendered on an inpatient or outpatient basis.

(26) Reasonable opportunity–At least one documented good faith attempt to contact the provider of record that provides an opportunity for the provider of record to discuss the services under review with the URA during normal business hours prior to issuing a prospective, concurrent, or retrospective utilization review adverse determination:

(A) no less than one working day prior to issuing a prospective utilization review adverse determination;

(B) no less than five working days prior to issuing a retrospective utilization review adverse determination; or

(C) prior to issuing a concurrent or post-stabilization review adverse determination.

(27) Registration–The process for a licensed insurance carrier or HMO to register with TDI to perform utilization review solely for its own enrollees.

(28) Request for a review by an IRO–Form to request a review by an independent review organization that is completed by the requesting party and submitted to the URA.

(29) Retrospective utilization review–A form of utilization review for health care services that have been provided to an enrollee. Retrospective utilization review does not include review of services for which prospective or concurrent utilization reviews were previously conducted or should have been previously conducted.

(30) Routine vision services–A routine annual or biennial eye examination to determine ocular health and refractive conditions that may include provision of glasses or contact lenses.

(31) Screening criteria–The written policies, decision rules, medical protocols, or treatment guidelines used by the URA as part of the utilization review process.

(32) TDI–The Texas Department of Insurance.

(33) URA–Utilization review agent.

(34) URA application–Form for application for, renewal of, and reporting a material change to a certification or registration as a URA in this state.

(35) Verification–A guarantee by an HMO or preferred provider benefit plan that the HMO or preferred provider benefit plan will pay for proposed medical care or health care services if the services are rendered within the required timeframe to the enrollee for whom the services are proposed. The term includes pre-certification, certification, re-certification, and any other term that would be a reliable representation by an HMO or preferred provider benefit plan to a physician or provider if the request for the pre-certification, certification, re-certification, or representation includes the requirements of §19.1719 of this title (relating to Verification for Health Maintenance Organizations and Preferred Provider Benefit Plans).

See https://texreg.sos.state.tx.us/public/readtac$ext.ViewTAC?tac_view=5&ti=28&pt=1&ch=19&sch=R&rl=Y

Section 19.1719. Verification for Health Maintenance Organizations and Preferred Provider Benefit Plans

(a) The words and terms defined in Insurance Code Chapter 1301, concerning Preferred Provider Benefit Plans, and Chapter 843, concerning Health Maintenance Organizations, have the same meaning when used in this section, except as otherwise provided by this subchapter, unless the context clearly indicates otherwise. This section applies to:

(1) HMOs;

(2) preferred provider benefit plans;

(3) preferred providers; and

(4) physicians, doctors, or other health care providers that provide to an enrollee of an HMO or preferred provider benefit plan:

(A) care related to an emergency or its attendant episode of care as required by state or federal law; or

(B) specialty or other medical care or health care services at the request of the HMO, preferred provider benefit plan, or a preferred provider because the services are not reasonably available from a preferred provider who is included in the HMO or preferred provider benefit plan’s network.

(b) An HMO or preferred provider benefit plan must be able to receive a request for verification of proposed medical care or health care services:

(1) by telephone call;

(2) in writing; and

(3) by other means, including the Internet, as agreed to by the preferred provider and the HMO or preferred provider benefit plan, provided that the agreement may not limit the preferred provider’s option to request a verification by telephone call.

(c) An HMO or preferred provider benefit plan must have appropriate personnel reasonably available at a toll-free telephone number under Insurance Code § 1301.133. The HMO or preferred provider benefit plan must acknowledge calls not later than:

(1) for requests relating to post-stabilization care or a life-threatening condition, within one hour after the beginning of the next time period requiring the availability of appropriate personnel at the toll-free telephone number;

(2) for requests relating to concurrent hospitalization, within 24 hours after the beginning of the next time period requiring the availability of appropriate personnel at the toll-free telephone number; and

(3) for all other requests, within two calendar days after the beginning of the next time period requiring the availability of appropriate personnel at the toll-free telephone number.

(d) Any request for verification must contain the following information:

(1) enrollee name;

(2) enrollee ID number, if included on an identification card issued by the HMO or preferred provider benefit plan;

(3) enrollee date of birth;

(4) name of enrollee or subscriber, if included on an identification card issued by the HMO or preferred provider benefit plan;

(5) enrollee relationship to enrollee or subscriber;

(6) presumptive diagnosis, if known; otherwise presenting symptoms;

(7) description of proposed procedures or procedure codes;

(8) place of service code where services will be provided and, if place of service is other than provider’s office or provider’s location, name of hospital or facility where proposed service will be provided;

(9) proposed date of service;

(10) group number, if included on an identification card issued by the HMO or preferred provider benefit plan;

(11) if known to the provider, name and contact information of any other carrier, including the name, address, and telephone number; name of enrollee; plan or ID number; group number (if applicable); and group name (if applicable);

(12) name of provider providing the proposed services; and

(13) provider’s federal tax ID number.

(e) Receipt of a written request or a written response to a request for verification under this section is subject to the provisions of § 21.2816 of this title (relating to Date of Receipt).

(f) If necessary to verify proposed medical care or health care services, an HMO or preferred provider benefit plan may, within one day of receipt of a request for verification, request information from the preferred provider in addition to the information provided in the request for verification. An HMO or preferred provider benefit plan may make only one request for additional information from the requesting preferred provider under this section.

(g) A request for information under subsection (f) of this section must:

(1) be specific to the verification request;

(2) describe with specificity the clinical and other information to be included in the response;

(3) be relevant and necessary for the resolution of the request; and

(4) be for information contained in or in the process of being incorporated into the enrollee’s medical or billing record maintained by the preferred provider.

(h) On receipt of a request for verification from a preferred provider, an HMO or preferred provider benefit plan must issue a verification or declination. The HMO or preferred provider benefit plan must issue the verification or declination within the following time periods.

(1) Except as provided in paragraphs (2) and (3) of this subsection, an HMO or preferred provider benefit plan must provide a verification or declination in response to a request for verification without delay, and as appropriate to the circumstances of the particular request, but not later than five calendar days after the date of receipt of the request for verification. If the request is received outside of the period requiring the availability of appropriate personnel as required in subsection (c) of this section, the determination must be provided within five calendar days from the beginning of the next time period requiring appropriate personnel.

(2) If the request is related to a concurrent hospitalization, the response must be sent to the preferred provider without delay but not later than 24 hours after the HMO or preferred provider benefit plan received the request for verification. If the request is received outside of the period requiring the availability of appropriate personnel as required in subsection (c) of this section, the determination must be provided within 24 hours from the beginning of the next time period requiring appropriate personnel.

(3) If the request is related to post-stabilization care or a life-threatening condition, the response must be sent to the preferred provider without delay but not later than one hour after the HMO or preferred provider benefit plan received the request for verification. If the request is received outside of the period requiring the availability of appropriate personnel as required in subsections (c) and (d) of this section, the determination must be provided within one hour from the beginning of the next time period requiring appropriate personnel.

(i) If the request involves services for which preauthorization is required, the HMO or preferred provider benefit plan must implement the procedures set forth in § 19.1718 of this title (relating to Preauthorization for Health Maintenance Organizations and Preferred Provider Benefit Plans) and respond regarding the preauthorization request in compliance with that section.

(j) A verification or declination may be delivered via telephone call, in writing, or by other means, including the Internet, as agreed to by the preferred provider and the HMO or preferred provider benefit plan. If a verification or declination is delivered via telephone call, the HMO or preferred provider benefit plan must, within three calendar days of providing a verbal response, provide a written response which must include, at a minimum:

(1) enrollee name;

(2) enrollee ID number;

(3) requesting provider’s name;

(4) hospital or other facility name, if applicable;

(5) a specific description, including relevant procedure codes, of the services that are verified or declined;

(6) if the services are verified, the effective period for the verification, which must not be less than 30 calendar days from the date of verification;

(7) if the services are verified, any applicable deductibles, copayments, or coinsurance for which the enrollee is responsible;

(8) if the verification is declined, the specific reason for the declination;

(9) a unique verification number that allows the HMO or preferred provider benefit plan to match the verification and subsequent claims related to the proposed service; and

(10) a statement that the proposed services are being verified or declined.

See https://texreg.sos.state.tx.us/public/readtac$ext.ViewTAC?tac_view=5&ti=28&pt=1&ch=19&sch=R&rl=Y