Tex.
Ins. Code Section 4201.659
Effect of Preauthorization Exemption
(a)
A health maintenance organization or insurer may not deny or reduce payment to a physician or provider for a health care service for which the physician or provider has qualified for an exemption from preauthorization requirements under Section 4201.653 (Exemption from Preauthorization Requirements for Physicians and Providers Providing Certain Health Care Services) based on medical necessity or appropriateness of care unless the physician or provider:(1)
knowingly and materially misrepresented the health care service in a request for payment submitted to the health maintenance organization or insurer with the specific intent to deceive and obtain an unlawful payment from the health maintenance organization or insurer; or(2)
failed to substantially perform the health care service.(b)
A health maintenance organization or an insurer may not conduct a retrospective review of a health care service subject to an exemption except:(1)
to determine if the physician or provider still qualifies for an exemption under this subchapter; or(2)
if the health maintenance organization or insurer has a reasonable cause to suspect a basis for denial exists under Subsection (a).(c)
For a retrospective review described by Subsection (b)(2), nothing in this subchapter may be construed to modify or otherwise affect:(1)
the requirements under or application of Section 4201.305 (Notice of Adverse Determination for Retrospective Utilization Review), including any timeframes specified by that section; or(2)
any other applicable law, except to prescribe the only circumstances under which:(A)
a retrospective utilization review may occur as specified by Subsection (b)(2); or(B)
payment may be denied or reduced as specified by Subsection (a).(d)
Not later than five days after qualifying for an exemption from preauthorization requirements under Section 4201.653 (Exemption from Preauthorization Requirements for Physicians and Providers Providing Certain Health Care Services), a health maintenance organization or insurer must provide to a physician or provider a notice that includes:(1)
a statement that the physician or provider qualifies for an exemption from preauthorization requirements under Section 4201.653 (Exemption from Preauthorization Requirements for Physicians and Providers Providing Certain Health Care Services);(2)
a list of the health care services and health benefit plans to which the exemption applies; and(3)
a statement of the duration of the exemption.(e)
If a physician or provider submits a preauthorization request for a health care service for which the physician or provider qualifies for an exemption from preauthorization requirements under Section 4201.653 (Exemption from Preauthorization Requirements for Physicians and Providers Providing Certain Health Care Services), the health maintenance organization or insurer must promptly provide a notice to the physician or provider that includes:(1)
the information described by Subsection (d); and(2)
a notification of the health maintenance organization’s or insurer’s payment requirements.(f)
Nothing in this subchapter may be construed to:(1)
authorize a physician or provider to provide a health care service outside the scope of the provider’s applicable license issued under Title 3, Occupations Code; or(2)
require a health maintenance organization or insurer to pay for a health care service described by Subdivision (1) that is performed in violation of the laws of this state.
Source:
Section 4201.659 — Effect of Preauthorization Exemption, https://statutes.capitol.texas.gov/Docs/IN/htm/IN.4201.htm#4201.659 (accessed Jun. 5, 2024).
