Tex.
Ins. Code Section 843.3481
Posting of Preauthorization Requirements
(a)
A health maintenance organization that uses a preauthorization process for health care services shall make the requirements and information about the preauthorization process readily accessible to enrollees, physicians, providers, and the general public by posting the requirements and information on the health maintenance organization’s Internet website.(b)
The preauthorization requirements and information described by Subsection (a) must:(1)
be posted:(A)
except as provided by Subsection (c) or (d), conspicuously in a location on the Internet website that does not require the use of a log-in or other input of personal information to view the information; and(B)
in a format that is easily searchable and accessible;(2)
except for the screening criteria under Subdivision (4)(C), be written in plain language that is easily understandable by enrollees, physicians, providers, and the general public;(3)
include a detailed description of the preauthorization process and procedure; and(4)
include an accurate and current list of the health care services for which the health maintenance organization requires preauthorization that includes the following information specific to each service:(A)
the effective date of the preauthorization requirement;(B)
a list or description of any supporting documentation that the health maintenance organization requires from the physician or provider ordering or requesting the service to approve a request for that service;(C)
the applicable screening criteria, which may include Current Procedural Terminology codes and International Classification of Diseases codes; and(D)
statistics regarding preauthorization approval and denial rates for the service in the preceding calendar year, including statistics in the following categories:(i)
physician or provider type and specialty, if any;(ii)
indication offered;(iii)
reasons for request denial;(iv)
denials overturned on internal appeal;(v)
denials overturned by an independent review organization; and(vi)
total annual preauthorization requests, approvals, and denials for the service.(c)
This section may not be construed to require a health maintenance organization to provide specific information that would violate any applicable copyright law or licensing agreement. To comply with a posting requirement described by Subsection (b), a health maintenance organization may, instead of making that information publicly available on the health maintenance organization’s Internet website, supply a summary of the withheld information sufficient to allow a licensed physician or provider, as applicable for the specific service, who has sufficient training and experience related to the service to understand the basis for the health maintenance organization’s medical necessity or appropriateness determinations.(d)
If a requirement or information described by Subsection (a) is licensed, proprietary, or copyrighted material that the health maintenance organization has received from a third party with which the health maintenance organization has contracted, to comply with a posting requirement described by Subsection (b), the health maintenance organization may, instead of making that information publicly available on the health maintenance organization’s Internet website, provide the material to a physician or provider who submits a preauthorization request using a nonpublic secured Internet website link or other protected, nonpublic electronic means.
Source:
Section 843.3481 — Posting of Preauthorization Requirements, https://statutes.capitol.texas.gov/Docs/IN/htm/IN.843.htm#843.3481 (accessed Jun. 5, 2024).
