Applicability; Exception; Definitions, Prior Authorization Request Form for Health Care Services, Required Acceptance, and Use; Prior Authorization Request Form for Prescription Drug Benefits, Required Acceptance, and Use
Rule 19.1801. Applicability
(a) Applicable health benefit plans. This subchapter applies only to a health benefit plan that provides benefits for medical or surgical expenses incurred as a result of a health condition, accident, or sickness, including an individual, group, blanket, or franchise insurance policy or insurance agreement, a group hospital service contract, or a small or large employer group contract or similar coverage document that is offered by:
(1) an insurance company;
(2) a group hospital service corporation operating under Chapter 842;
(3) a fraternal benefit society operating under Chapter 885;
(4) a stipulated premium company operating under Chapter 884;
(5) a reciprocal exchange operating under Chapter 942;
(6) a health maintenance organization operating under Chapter 843;
(7) a multiple employer welfare arrangement holding a certificate of authority under Chapter 846; or
(8) an approved nonprofit health corporation holding a certificate of authority under Chapter 844.
(b) Other applicable coverages and programs.
(1) This subchapter applies to group health coverage made available by a school district under Education Code §22.004.
(2) This subchapter applies to:
(A) a basic coverage plan under Chapter 1551;
(B) a basic plan under Chapter 1575;
(C) a primary care coverage plan under Chapter 1579; and
(D) basic coverage under Chapter 1601.
(3) This subchapter applies to coverage under the child health program under Chapter 62, Health and Safety Code, or the health benefits plan for children under Chapter 63, Health and Safety Code.
(4) This subchapter applies to a Medicaid managed care program operated under Chapter 533, Government Code, or a Medicaid program operated under Chapter 32, Human Resources Code.
Rule §19.1802. Exception
This subchapter does not apply to:
(1) a health benefit plan that provides coverage:
(A) only for a specified disease or for another single benefit;
(B) only for accidental death or dismemberment;
(C) only for wages or payments to replace wages for a period during which an employee is absent from work because of sickness or injury;
(D) as a supplement to a liability insurance policy;
(E) for credit insurance;
(F) only for dental or vision care;
(G) only for hospital expenses; or
(H) only for indemnity for hospital confinement;
(2) a Medicare supplemental policy as defined by §1882, Social Security Act (42 U.S.C. §1395ss);
(3) medical payment insurance coverage provided under a motor vehicle insurance policy;
(4) a long-term care insurance policy, including a nursing home fixed indemnity policy, unless the commissioner determines that the policy provides benefit coverage so comprehensive that the policy is a health benefit plan as described by §1217.002 or §1369.252; or
(5) a workers’ compensation insurance policy.
Rule 19.1803. Definitions
The following words and terms, when used in this subchapter, have the following meanings unless the context clearly indicates otherwise:
(1) CDT–Current Dental Terminology code set maintained by the American Dental Association.
(2) CPT–Current Procedural Terminology code set maintained by the American Medical Association.
(3) Department or TDI–Texas Department of Insurance.
(4) Form–In Division 2 of this subchapter, the Texas Standard Prior Authorization Request Form for Health Care Services. In Division 3 of this subchapter, the Texas Standard Prior Authorization Request Form for Prescription Drug Benefits.
(5) HCPCS–Healthcare Common Procedure Coding System.
(6) Health benefit plan–
(A) a plan that provides benefits for medical or surgical expenses incurred as a result of a health condition, accident, or sickness, including an individual, group, blanket, or franchise insurance policy or insurance agreement, a group hospital service contract, or a small or large employer group contract or similar coverage document offered by a health benefit plan issuer.
(B) Health benefit plan also includes:
(i) group health coverage made available by a school district in accord with Education Code §22.004;
(ii) coverage under the child health program in Health and Safety Code Chapter 62, or the health benefits plan for children in Health and Safety Code Chapter 63;
(iii) a Medicaid managed care program operated under Government Code Chapter 533, or a Medicaid program operated under Human Resources Code Chapter 32;
(iv) a basic coverage plan under Insurance Code Chapter 1551;
(v) a basic plan under Insurance Code Chapter 1575;
(vi) a primary care coverage plan under Insurance Code Chapter 1579; and
(vii) basic coverage under Insurance Code Chapter 1601.
(7) Health benefit plan issuer–An entity authorized under the Insurance Code or another insurance law of this state that delivers or issues for delivery a health benefit plan or other coverage described in Insurance Code §1217.002 or Insurance Code §1369.252.
(8) Health care service–A service to diagnose, prevent, alleviate, cure, or heal a human illness or injury that is provided by a physician or other health care provider. The term includes medical or health care treatments, consultations, procedures, drugs, supplies, imaging and diagnostic services, inpatient and outpatient care, medical devices other than those included in the definition of prescription drugs in Occupations Code §551.003, and durable medical equipment. The term does not include prescription drugs or devices as defined by Occupations Code §551.003.
(9) ICD–International Classification of Diseases.
(10) Issuer–A health benefit plan issuer and the agent of a health benefit plan issuer that manages or administers the issuer’s health care services or prescription drug benefits.
(11) NDC–National Drug Code.
(12) NPI number–A provider’s or facility’s National Provider Identifier.
(13) Prescription drug–Has the meaning assigned by Occupations Code §551.003.
(a) Form requirements. The commissioner adopts by reference the Prior Authorization Request Form for Health Care Services, to be accepted and used by an issuer in compliance with subsection (b) of this section. The form and its instruction sheet are posted on the TDI website at www.tdi.texas.gov/forms/form10.html; or the form and its instruction sheet can be requested by mail from the Texas Department of Insurance, Rate and Form Review Office, MC: LH-MCQA, P.O. Box 12030, Austin, Texas 78711-2030. The form must be reproduced without changes. The form provides space for the following information:
(1) the plan issuer’s name, telephone number, and facsimile (fax) number;
(2) the date the request is submitted;
(3) the type of review, whether:
(A) nonurgent; or
(B) urgent. An urgent review should only be requested for a patient with a life-threatening condition or for a patient who is currently hospitalized, or to authorize treatment following stabilization of an emergency condition. A provider or facility may also request an urgent review to authorize treatment of an acute injury or illness if the provider determines that the condition is severe or painful enough to warrant an expedited or urgent review to prevent a serious deterioration of the patient’s condition or health;
(4) the type of request (whether an initial request or an extension, renewal, or amendment of a previous authorization);
(5) the patient’s name, date of birth, sex, contact telephone number, and identifying insurance information;
(6) the requesting provider’s or facility’s name, NPI number, specialty, telephone and fax numbers, contact person’s name and telephone number, and the requesting provider’s signature and date, if required (if a signature is required, a signature stamp may not be used);
(7) the service provider’s or facility’s name, NPI number, specialty, and telephone and fax numbers;
(8) the primary care provider’s name and telephone and fax numbers, if the patient’s plan requires the patient to have a primary care provider and that provider is not the requesting provider;
(9) the planned services or procedures and the associated CPT, CDT, or HCPCS codes, and the planned start
and end dates of the services or procedures;
(10) the diagnosis description, ICD version number (if more than one version is allowed by the U.S. Department of Health and Human Services), and ICD code;
(11) identification of the treatment location (inpatient, outpatient, provider office, observation, home, day
surgery, or other specified location);
(12) information about the duration and frequency of treatment sessions for physical, occupational, or speech therapy, cardiac rehabilitation, mental health, or substance abuse;
(13) if requesting prior authorization for home health care, information about the requested number of home health visits and their duration and frequency, and an indication whether a physician’s signed order or a nursing assessment is attached;
(14) if requesting prior authorization for durable medical equipment, an indication whether a physician’s signed order is attached, a description of requested equipment or supplies with associated HCPCS codes, duration, and, if the patient is a Medicaid beneficiary, an indication whether a Title 19 Certification is attached;
(15) a place for the requester to include a brief narrative of medical necessity or other clinical documentation. A requesting provider or facility may also attach a narrative of medical necessity and supporting clinical documentation (medical records, progress notes, lab reports, radiology studies, etc.); and
(16) if a requesting provider wants to be called directly about missing information, a place to list a direct telephone number for the requesting provider or facility the issuer can call to ask for additional or missing information if needed to process the request. The phone call can only be considered a peer-to-peer discussion required by §19.1710 of this title (relating to Requirements Prior to Issuing an Adverse Determination) if it is a discussion between peers that includes, at a minimum, the clinical basis for the URA’s decision and a description of documentation or evidence, if any, that can be submitted by the provider of record that, on appeal, might lead to a different utilization review decision.
(b) Acceptance and use of the form.
(1) If a provider or facility submits the form to request prior authorization of a health care service for which the issuer’s plan requires prior authorization, the issuer must accept and use the form for that purpose. An issuer may also have on its website another electronic process a provider or facility may use to request prior authorization of a health care service.
(2) This form may not be used by a provider or facility:
(A) to request an appeal;
(B) to confirm eligibility;
(C) to verify coverage;
(D) to ask whether a service requires prior authorization;
(E) to request prior authorization of a prescription drug; or
(F) to request a referral to an out of network physician facility or other health care provider.
(c) Effective date. An issuer must accept a request for prior authorization of health care services made by a provider or facility using the form on or after September 1, 2015.
(d) Availability of the form.
(1) A health benefit plan issuer must make the form available on paper and electronically on its website.
(2) A health benefit plan issuer’s agent that manages or administers health care services benefits must make the form available on paper and electronically on its website.
Filed with the Office of the Secretary of State on May 30, 2023. This section was updated on July 23, 2023
Rule 19.1820. Prior Authorization Request Form for Prescription Drug Benefits, Required Acceptance, and Use
(a) Form requirements. The commissioner adopts by reference the Prior Authorization Request Form for Prescription Drug Benefits form, to be accepted and used by an issuer in compliance with subsection (b) of this section. The form and its instruction sheet are on TDI’s website at www.tdi.texas.gov/forms/form10.html; or the form and its instruction sheet can be requested by mail from the Texas Department of Insurance, Rate and Form Review Office, MC: LH-MCQA, PO Box 12030, Austin, Texas 78711-2030. The form must be reproduced without changes. The form provides space for the following information:
(1) the name of the issuer or the issuer’s agent that manages prescription drug benefits, telephone number, and fax number;
(2) the date the request is submitted;
(3) a place to request an expedited or urgent review if the prescribing provider or the prescribing provider’s designee certifies that applying the standard review time frame may seriously jeopardize the life or health of the patient or the patient’s ability to regain maximum function;
(4) the patient’s name, contact telephone number, date of birth, sex, address, and identifying insurance information;
(5) the prescribing provider’s name, NPI number, specialty, telephone and fax numbers, address, and contact person’s name and telephone number;
(6) for a prescription drug:
(A) drug name;
(B) strength;
(C) route of administration;
(D) quantity;
(E) number of days’ supply;
(F) expected therapy duration; and
(G) to the best of the prescribing provider’s knowledge, whether the medication is:
(i) a new therapy; or
(ii) continuation of therapy, and if so, to the best of the prescribing provider’s knowledge:
(I) the approximate date therapy was initiated;
(II) whether the patient is adhering to the drug therapy regimen; and
(III) whether the drug therapy regimen is effective;
(7) for a provider administered drug, the HCPCS code, NDC number, and dose per administration;
(8) for a prescription compound drug, its name, ingredients, and each ingredient’s NDC number and quantity;
(9) for a prescription device, its name, expected duration of use, and, if applicable, its HCPCS code;
(10) the patient’s clinical information, including:
(A) diagnosis, ICD version number (if more than one version is allowed by the U.S. Department of Health and Human Services), and ICD code;
(B) to the best of the prescribing provider’s knowledge, the drugs the patient has taken for this diagnosis, including:
(i) drug name, strength, and frequency;
(ii) the approximate dates or duration the drugs were taken; and
(iii) patient’s response, reason for failure, or allergic reaction;
(C) the patient’s drug allergies, if any; and
(D) the patient’s height and weight, if relevant;
(11) a list of relevant lab tests, and their dates and values;
(12) a place for the prescribing provider to:
(A) include pertinent clinical information to justify requests for initial or ongoing therapy, or increases in current dosage, strength, or frequency;
(B) explain any comorbid conditions and contraindications for formulary drugs; or
(C) provide details regarding titration regimen or oncology staging, if applicable; and
(13) a directive to the prescribing provider stating that:
(A) for a request for prior authorization of continuation of therapy (other than a request for a step-therapy exception as provided in subparagraph (B) of this paragraph), it is not necessary to complete the sections of the form regarding patient clinical information and justification for the therapy unless there has been a material change in the information previously provided; and
(B) for a request for a step-therapy exception, the section of the form regarding justification for the step-therapy exception must be completed.
(b) Acceptance and use of the form.
(1) If a prescribing provider submits the form to request prior authorization of a prescription drug benefit for which the issuer’s plan requires prior authorization, the issuer must accept and use the form for that purpose. An issuer may also have on its website another electronic process a prescribing provider may use to request prior authorization of a prescription drug benefit.
(2) This form may be used by a prescribing provider to request prior authorization of:
(A) a prescription drug;
(B) a prescription device;
(C) formulary exceptions;
(D) quantity limit overrides; and
(E) step-therapy requirement exceptions.
(3) This form may not be used by a prescribing provider to:
(A) request an appeal;
(B) confirm eligibility;
(C) verify coverage;
(D) ask whether a prescription drug or device requires prior authorization; or
(E) request prior authorization of a health care service.
(c) Effective date. An issuer must accept a request for prior authorization of prescription drug benefits made by a prescribing provider using the form on or after the effective date of this section. An issuer must accept a request using the form that was in place prior to the effective date of this section for 90 days after the effective date.
(d) Availability of the form.
(1) A health benefit plan issuer must make the form available electronically on its website.
(2) A health benefit plan issuer’s agent that manages or administers prescription drug benefits must make the form available electronically on its website.