Part 1.
TEXAS DEPARTMENT OF INSURANCE
Chapter 3.
LIFE, ACCIDENT AND HEALTH INSURANCE AND ANNUITIES
Subchapter X. PREFERRED PROVIDER PLANS
28 TAC §3.3703
The Commissioner of Insurance adopts on an emergency basis,
to take effect on August 16, 2003, amendments to §3.3703, concerning
required contracting provisions for preferred provider plans. The emergency
adoption is necessary to comply with and implement the provisions and the
intent of Senate Bill 418 (SB 418) (78th regular legislative session) within
the statutory timetable prescribed by SB 418. The amendments to §3.3703
relate to the coding guidelines and other claims payment information that
a preferred provider carrier must supply upon request from a preferred provider
pursuant to a preferred provider contract subject to Texas Insurance Code
Art. 3.70-3C. Pursuant to SB 418, several provisions become effective 60 days
after the effective date of the statute, June 17, 2003, rendering these provisions
effective on August 16, 2003. SB 418 further provides that the Commissioner
of Insurance may adopt emergency rules to implement this Act without making
the finding in subsection (a), Section 2001.034, Government Code. An emergency
adoption is warranted so that rules are in place on the effective date of
certain provisions of the statute, to facilitate the uniform implementation
of these amendments and to guide affected parties' compliance with the new
statutory requirements. SB 418 requires the commissioner, not later than 90
days after the Act's effective date, to adopt rules to implement the Act.
It also requires that the commissioner appoint a "technical advisory committee
on claims processing" (TACCP) and to consult with the TACCP with respect to,
among other things, "the implementation of the standardized coding and bundling
edits and logic" before adopting any rule related to such subjects. Following
consultation with the TACCP, as well as with the Clean Claims Working Group,
TDI on July 4, 2003 proposed for public comment rules to implement most of
the requirements of SB 418, and held a public hearing on the rules on August
7, 2003. More than 150 comments were received on the proposal. While the department
intends to adopt final rules in the near future, the usual process of rule
adoption and its associated notice and comment periods, as well as the need
to respond to comments, would have required a timeframe that could not be
completed prior to the date affected entities must begin complying with certain
provisions of the new statute. Considering these facts, it is necessary to
adopt these amendments on an emergency basis to ensure that physicians and
providers are paid timely for their services and to promote regulatory compliance.
The amendments to §3.3703, subsection (a)(20) and (a)(20)(F) delete
outdated compliance language. The amendments to subsection (a)(20)(A) require
that disclosed bundling processes be consistent with nationally recognized
and generally accepted bundling edits and logic; they also add the publisher,
product name and version of any software the insurer uses to determine bundling
and unbundling of claims to the list of information to be disclosed. The amendments
to subsection (a)(20)(D) require the insurer to give 90 calendar days written
notice of any changes to claims payment procedures, and provide that an insurer
may not make retroactive changes to claims payment procedures or any of the
information required to be provided by paragraph (20). Subsection (a)(20)(G)
adds "other business operations" and "communications with a governmental agency
involved in the regulation of health care or insurance" to the list of acceptable
uses of disclosed information. The amendments to that paragraph also replace
the term "verification" with "representation" to avoid confusion with the
verification provisions established pursuant to SB 418. Subsection (a)(20)(H)
allows a preferred provider that receives information under the disclosure
requirements to terminate its contract with an insurer, on or before the 30th
day after the date the preferred provider receives the information, without
penalty or discrimination in participation in other products or plans so long
as proper notice is given to insureds in compliance with existing law. Subsection
(a)(20)(I) provides that the provisions of this paragraph may not be waived,
voided, or nullified by contract. Subsection (a)(21) provides that an insurer
may require a preferred provider to retain in that provider's records updated
information concerning a patient's other health benefit plan coverage.
The sections are adopted on an emergency basis under SB 418,
Government Code §2001.034, and Insurance Code Article 3.70-3C and §36.001.
SB 418 provides that the commissioner shall adopt rules as necessary to implement
that Act, including emergency adoption of rules pursuant to §2001.034
of the Government Code without a finding described in subsection (a) of that
provision. Government Code §2001.034 provides for the adoption of administrative
rules on an emergency basis without notice and comment. Article 3.70-3C, Section
3A(p) gives the Commissioner the authority to adopt rules as necessary to
implement Article 3.70-3C, Section 3A. Article 3.70-3C, Section 3A(m) states
that an insurer's claims payment processes shall be consistent with nationally
recognized, generally accepted bundling edits and logic. Article 3.70-3C,
Section 3F provides in part that an insurer may require a physician or provider
to retain in the physician's or provider's records updated information concerning
other health benefit plan coverage. Article 3.70-3C, Section 3H contains requirements
and procedures by which coding, bundling, or other payment processes and fee
schedules may be requested, and must be provided, pursuant to a contract between
an insurer and a physician or provider. Article 3.70-3C, Section 6(e)(2) provides
that a preferred provider that voluntarily terminates the preferred provider's
relationship with the insurer shall provide notice to insureds of the termination,
with the assistance of the insurer. Section 36.001 provides that the Commissioner
of Insurance may adopt any rules necessary and appropriate to implement the
powers and duties of the Texas Department of Insurance under the Insurance
Code and other laws of this state.
§3.3703.Contracting Requirements.
(a)
An insurer marketing a preferred provider benefit plan
must contract with physicians and health care providers to assure that all
medical and health care services and items contained in the package of benefits
for which coverage is provided, including treatment of illnesses and injuries,
will be provided under the plan in a manner that assures both availability
and accessibility of adequate personnel, specialty care, and facilities. Each
contract must meet the following requirements:
(1) - (19)
(No change.)
(20)
A contract between a preferred provider and an insurer
must include provisions that will entitle the preferred provider upon request
to all information necessary to determine that the preferred provider is being
compensated in accordance with the contract. A preferred provider may make
the request for information by any reasonable and verifiable means. The information
must include a level of detail sufficient to enable a reasonable person with
sufficient training, experience and competence in claims processing to determine
the payment to be made according to the terms of the contract for covered
services that are rendered to insureds. The insurer may provide the required
information by any reasonable method through which the preferred provider
can access the information, including e-mail, computer disks, paper or access
to an electronic database. Amendments, revisions or substitutions of any information
provided pursuant to this paragraph must be made in accordance with subparagraph
(D) of this paragraph. The insurer shall provide the fee schedules and other
required information by the 30th day after the date the insurer receives the
preferred provider's request.
(A)
This information must include a preferred provider specific
summary and explanation of all payment and reimbursement methodologies that
will be used to pay claims submitted by the preferred provider. At a minimum,
the information must include:
(i)
a fee schedule, including, if applicable, CPT, HCPCS, ICD-9-CM
codes and modifiers:
(I)
by which all claims for covered services submitted by or
on behalf of the preferred provider will be calculated and paid; or
(II)
that pertains to the range of health care services reasonably
expected to be delivered under the contract by that preferred provider on
a routine basis along with a toll-free number or electronic address through
which the preferred provider may request the fee schedules applicable to any
covered services that the preferred provider intends to provide to an insured
and any other information required by this paragraph that pertains to the
service for which the fee schedule is being requested if that information
has not previously been provided to the preferred provider;
(ii)
all applicable coding methodologies;
(iii)
all applicable bundling processes, which must be consistent
with nationally recognized and generally accepted bundling edits and logic;
(iv)
all applicable downcoding policies;
(v)
a description of any other applicable policy or procedure
the insurer may use that affects the payment of specific claims submitted
by or on behalf of the preferred provider, including recoupment;
(vi)
any addenda, schedules, exhibits or policies used by the
insurer in carrying out the payment of claims submitted by or on behalf of
the preferred provider that are necessary to provide a reasonable understanding
of the information provided pursuant to this paragraph; and
(vii)
the publisher, product name and version of any software
the insurer uses to determine bundling and unbundling of claims.
(B)
In the case of a reference to source information as the
basis for fee computation that is outside the control of the insurer, such
as state Medicaid or federal Medicare fee schedules, the information provided
by the insurer shall clearly identify the source and explain the procedure
by which the preferred provider may readily access the source electronically,
telephonically, or as otherwise agreed to by the parties.
(C)
Nothing in this paragraph shall be construed to require
an insurer to provide specific information that would violate any applicable
copyright law or licensing agreement. However, the insurer must supply, in
lieu of any information withheld on the basis of copyright law or licensing
agreement, a summary of the information that will allow a reasonable person
with sufficient training, experience and competence in claims processing to
determine the payment to be made according to the terms of the contract for
covered services that are rendered to insureds as required by subparagraph
(A) of this paragraph.
(D)
No amendment, revision, or substitution of claims payment
procedures or any of the information required to be provided by this paragraph
shall be effective as to the preferred provider, unless the insurer provides
at least 90 calendar days written notice to the preferred provider identifying
with specificity the amendment, revision or substitution. An insurer may not
make retroactive changes to claims payment procedures or any of the information
required to be provided by this paragraph. Where a contract specifies mutual
agreement of the parties as the sole mechanism for requiring amendment, revision
or substitution of the information required by this paragraph, the written
notice specified in this section does not supersede the requirement for mutual
agreement.
(E)
Failure to comply with this paragraph constitutes a violation
as set forth in subsection (b) of this section.
(F)
This paragraph applies to all contracts entered into or
renewed on or after the effective date of this paragraph. Upon receipt of
a request, the insurer must provide the information required by subparagraphs
(A)-(D) of this paragraph to the preferred provider by the 30th day after
the date the insurer receives the preferred provider's request.
(G)
A preferred provider that receives information under this
paragraph:
(i)
may not use or disclose the information for any purpose
other than:
(I)
the preferred provider's practice management,
(II)
billing activities,
(III)
other business operations, or
(IV)
communications with a governmental agency involved in
the regulation of health care or insurance; and
(ii)
may not use this information to knowingly submit a claim
for payment that does not accurately represent the level, type or amount of
services that were actually provided to an insured or to misrepresent any
aspect of the services; and
(iii)
may not rely upon information provided pursuant to this
paragraph about a service as a representation that an insured is covered for
that service under the terms of the insured's policy or certificate.
(H)
A preferred provider that receives information under this
paragraph may terminate the contract on or before the 30th day after the date
the preferred provider receives the requested information without penalty
or discrimination in participation in other health care products or plans.
If a preferred provider chooses to terminate the contract, the insurer shall
assist the preferred provider in providing the notice required by paragraph
(18) of this subsection.
(I)
The provisions of this paragraph may not be waived, voided,
or nullified by contract.
(21)
An insurer may require a preferred provider to retain
in the preferred provider's records updated information concerning a patient's
other health benefit plan coverage.
(b)
In addition to all other contract rights, violations of
these rules shall be treated for purposes of complaint and action in accordance
with Insurance Code Article 21.21-2, and the provisions of that article shall
be utilized insofar as practicable, as it relates to the power of the department,
hearings, orders, enforcement, and penalties.
(c)
An insurer may enter into an agreement with a preferred
provider organization for the purpose of offering a network of preferred providers,
provided that it remains the insurer's responsibility to:
(1)
meet the requirements of Insurance Code Article 3.70-3C
(Preferred Provider Benefit Plans) and this subchapter; or
(2)
ensure that the requirements of Insurance Code Article
3.70-3C (Preferred Provider Benefit Plans) and this subchapter are met.
This agency hereby certifies that the emergency adoption
has been reviewed by legal counsel and found to be within the agency's legal
authority to adopt.
Filed with the Office of
the Secretary of State on August 15, 2003.
TRD-200305224
Gene C. Jarmon
General Counsel and Chief Clerk
Texas Department of Insurance
Effective Date: August 16, 2003
Expiration Date: December 14, 2003
For further information, please call: (512) 463-6327
Subchapter J. PHYSICIAN AND PROVIDER CONTRACTS AND ARRANGEMENTS
28 TAC §11.901
The Commissioner of Insurance adopts on an emergency basis,
to take effect on August 16, 2003, amendments to §11.901 concerning required
contracting provisions for health maintenance organizations (HMOs). The emergency
adoption is necessary to comply with and implement the provisions and intent
of Senate Bill 418 (SB 418) (78th regular legislative session) within the
statutory timetable prescribed by SB 418. The amendments to §11.901 relate
to the coding guidelines and other claims payment information that an HMO
must supply upon request from a physician or provider pursuant to an HMO contract
subject to Texas Insurance Code Chapter 843, Subchapter J.
Pursuant to SB 418, several provisions become effective 60 days after the
effective date of the statute, June 17, 2003, rendering these provisions effective
on August 16, 2003. SB 418 further provides that the Commissioner of Insurance
may adopt emergency rules to implement this Act without making the finding
in subsection (a), Section 2001.034, Government Code. An emergency adoption
is warranted so that rules are in place on the effective date of certain provisions
of the statute, to facilitate the uniform implementation of these amendments,
and to guide affected parties' compliance with the new statutory requirements.
SB 418 requires the commissioner, not later than 90 days after the Act's effective
date, to adopt rules to implement the Act. It also requires that the commissioner
appoint a "technical advisory committee on claims processing" (TACCP) and
to consult with the TACCP with respect to, among other things, "the implementation
of the standardized coding and bundling edits and logic" before adopting any
rule related to such subjects. Following consultation with the TACCP, as well
as with the Clean Claims Working Group, the Texas Department of Insurance
on July 4, 2003 proposed for public comment rules to implement most of the
requirements of SB 418, and held a public hearing on the rules on August 7,
2003. More than 150 comments were received on the proposal. While the department
intends to adopt final rules in the near future, the usual process of rule
adoption and its associated notice and comment periods, as well as the need
to respond to comments, would have required a timeframe that could not be
completed prior to the date affected entities must begin complying with certain
provisions of the new statute. Considering these facts, it is necessary to
adopt these amendments on an emergency basis to ensure that physicians and
providers are paid timely for their services and to promote regulatory compliance.
The amendments to §11.901, paragraphs (10) and (10)(F) delete outdated
compliance language. The amendments to paragraph (10)(A)(iii) and (iv) require
that disclosed bundling processes be consistent with nationally recognized
and generally accepted bundling edits and logic and add the publisher, product
name and version of any software the HMO uses to determine bundling and unbundling
of claims to the list of information to be disclosed. The amendments to paragraph
(10)(D) require the HMO to give 90 calendar days written notice of any changes
to claims payment procedures, and provide that an HMO may not make retroactive
changes to claims payment procedures or any of the information required to
be provided by paragraph (10). Paragraph (10)(G) adds "other business operations"
and "communications with a governmental agency involved in the regulation
of health care or insurance" to the list of acceptable uses of disclosed information.
The amendments to that paragraph also replace the term "verification" with
"representation" to avoid confusion with the verification provisions established
pursuant to SB 418.
Paragraph (10)(H) allows a physician or provider that receives information
under the disclosure requirements to terminate its contract with an HMO, on
or before the 30th day after the date the physician or provider receives the
information, without penalty or discrimination in participation in other products
or plans so long as proper notice is given to enrollees in compliance with
existing law. Paragraph (10)(I) provides that the provisions of this paragraph
may not be waived, voided, or nullified by contract. Paragraph (11) provides
that an HMO may require a contracting physician or provider to retain in that
physician's or provider's records updated information concerning a patient's
other health benefit plan coverage.
STATUTORY AUTHORITY. The sections are adopted on an emergency
basis under SB 418, Government Code §2001.034, and Insurance Code §§843.309,
843.319, 843.341, 843.349 and 36.001. SB 418 provides that the commissioner
shall adopt rules as necessary to implement that Act, including emergency
adoption of rules pursuant to §2001.034 of the Government Code without
a finding described in subsection (a) of that provision. Government Code §2001.034
provides for the adoption of administrative rules on an emergency basis without
notice and comment. Section 843.341(b) states that an HMO's claims payment
processes shall be consistent with nationally recognized, generally accepted
bundling edits and logic. Section 843.349(a) provides in part that an HMO
may require a physician or provider to retain in the physician's or provider's
records updated information concerning other health benefit plan coverage.
Section 843.319 contains requirements and procedures by which coding, bundling,
or other payment processes and fee schedules may be requested, and must be
provided, pursuant to a contract between an HMO and a physician or provider.
Section 843.309 requires an HMO's contract with a physician or provider to
provide for reasonable advance notice to enrollees of termination of a physician
or provider from the HMO's network. Section 36.001 provides that the Commissioner
of Insurance may adopt any rules necessary and appropriate to implement the
powers and duties of the Texas Department of Insurance under the Insurance
Code and other laws of this state.
§11.901.Required Provisions.
Physician and provider contracts and arrangements shall include the
following provisions:
(1) - (9)
(No change.)
(10)
entitling the physician or provider upon request to all
information necessary to determine that the physician or provider is being
compensated in accordance with the contract. A physician or provider may make
the request for information by any reasonable and verifiable means. The information
must include a level of detail sufficient to enable a reasonable person with
sufficient training, experience and competence in claims processing to determine
the payment to be made according to the terms of the contract for covered
services that are rendered to enrollees. The HMO may provide the required
information by any reasonable method through which the physician or provider
can access the information, including e-mail, computer disks, paper or access
to an electronic database. Amendments, revisions or substitutions of any information
provided pursuant to this paragraph must be made in accordance with subparagraph
(D) of this paragraph. The HMO shall provide the fee schedules and other required
information by the 30th day after the date the HMO receives the physician's
or provider's request.
(A)
This information must include a physician-specific or provider-specific
summary and explanation of all payment and reimbursement methodologies that
will be used to pay claims submitted by a physician or provider. At a minimum,
the information must include:
(i)
a fee schedule, including, if applicable, CPT, HCPCS, ICD-9-CM
codes and modifiers:
(I)
by which all claims for covered services submitted by or
on behalf of the contracting physician or provider will be calculated and
paid; or
(II)
that pertains to the range of health care services reasonably
expected to be delivered under the contract by that contracting physician
or provider on a routine basis along with a toll-free number or electronic
address through which the contracting physician or provider may request the
fee schedules applicable to any covered services that the physician or provider
intends to provide to an enrollee and any other information required by this
paragraph, that pertains to the service for which the fee schedule is being
requested if that information has not previously been provided to the physician
or provider;
(ii)
all applicable coding methodologies;
(iii)
all applicable bundling processes, which must be consistent
with nationally recognized and generally accepted bundling edits and logic;
(iv)
all applicable downcoding policies;
(v)
a description of any other applicable policy or procedure
the HMO may use that affects the payment of specific claims submitted by or
on behalf of the contracting physician or provider, including recoupment;
(vi)
any addenda, schedules, exhibits or policies used by the
HMO in carrying out the payment of claims submitted by or on behalf of the
contracting physician or provider that are necessary to provide a reasonable
understanding of the information provided pursuant to this paragraph; and
(vii)
the publisher, product name and version of any software
the HMO uses to determine bundling and unbundling of claims.
(B)
In the case of a reference to source information as the
basis for fee computation that is outside the control of the HMO, such as
state Medicaid or federal Medicare fee schedules, the information provided
by the HMO shall clearly identify the source and explain the procedure by
which the physician or provider may readily access the source electronically,
telephonically, or as otherwise agreed to by the parties.
(C)
Nothing in this paragraph shall be construed to require
an HMO to provide specific information that would violate any applicable copyright
law or licensing agreement. However, the HMO must supply, in lieu of any information
withheld on the basis of copyright law or licensing agreement, a summary of
the information that will allow a reasonable person with sufficient training,
experience and competence in claims processing to determine the payment to
be made according to the terms of the contract for covered services that are
rendered to enrollees as required by subparagraph (A) of this paragraph.
(D)
No amendment, revision, or substitution of any of the claims
payment procedures or any of the information required to be provided by this
paragraph shall be effective as to the contracting physician or provider,
unless the HMO provides at least 90 calendar days written notice to the contracting
physician or provider identifying with specificity the amendment, revision
or substitution. An HMO may not make retroactive changes to claims payment
procedures or any of the information required to be provided by this paragraph.
Where a contract specifies mutual agreement of the parties as the sole mechanism
for requiring amendment, revision or substitution of the information required
by this paragraph, the written notice specified in this section does not supersede
the requirement for mutual agreement.
(E)
Failure to comply with this paragraph constitutes a violation
of Insurance Code Chapter 20A (Texas Health Maintenance Organization Act).
(F)
This paragraph applies to all contracts entered into or
renewed on or after the effective date of this paragraph. Upon receipt of
a request, the HMO must provide the information required by subparagraphs
(A)-(D) of this paragraph to the contracting physician or provider by the
30th day after the date the HMO receives the contracting physician's or provider's
request.
(G)
A physician or provider that receives information under
this paragraph:
(i)
may not use or disclose the information for any purpose
other than:
(I)
the physician's or provider's practice management,
(II)
billing activities,
(III)
other business operations, or
(IV)
communications with a governmental agency involved in
the regulation of health care or insurance;
(ii)
may not use this information to knowingly submit a claim
for payment that does not accurately represent the level, type or amount of
services that were actually provided to an enrollee or to misrepresent any
aspect of the services; and
(iii)
may not rely upon information provided pursuant to this
paragraph about a service as a representation that an enrollee is covered
for that service under the terms of the enrollee's evidence of coverage.
(H)
A physician or provider that receives information under
this paragraph may terminate the contract on or before the 30th day after
the date the physician or provider receives the requested information without
penalty or discrimination in participation in other health care products or
plans. The contract between the HMO and physician or provider shall provide
for reasonable advance notice to enrollees being treated by the physician
or provider prior to the termination consistent with Insurance Code §843.309.
(I)
The provisions of this paragraph may not be waived, voided,
or nullified by contract.
(11)
An HMO may require a contracting physician or provider
to retain in the contracting physician or provider's records updated information
concerning a patient's other health benefit plan coverage.
This agency hereby certifies that the emergency adoption
has been reviewed by legal counsel and found to be within the agency's legal
authority to adopt.
Filed with the Office of
the Secretary of State on August 15, 2003.
TRD-200305226
Gene C. Jarmon
General Counsel and Chief Clerk
Texas Department of Insurance
Effective Date: August 16, 2003
Expiration Date: December 14, 2003
For further information, please call: (512) 463-6327
Subchapter R. UTILIZATION REVIEW AGENTS
28 TAC §§19.1703, 19.1723, 19.1724
The Commissioner of Insurance adopts, on an emergency basis,
to take effect on August 16, 2003, amendments to §19.1703 and new §19.1723
and §19.1724 concerning procedures by which preferred providers that
contract with an insurer or health maintenance organization (hereinafter referred
to as "physicians and providers") may request, and insurers that issue preferred
provider benefit plans and health maintenance organizations (hereinafter collectively
"carriers") may provide, preauthorization and verification of medical care
or health care services. The emergency adoption is necessary to comply with
and implement the provisions and the intent of Senate Bill 418 (SB 418) (78th
regular legislative session) by amending Texas Insurance Code Art. 3.70-3C,
concerning preferred provider benefit plans, and the HMO Act, Insurance Code
Chapter 843, to ensure that the procedures and requirements governing the
processing and payment of clean claims submitted by physicians and providers
are streamlined, standardized, and efficient. Among other things, SB 418 sets
forth the concepts of preauthorization, where the medical necessity and appropriateness
of services are determined, and verification, which is a reliable representation
by a carrier that it will pay a physician or provider for proposed medical
services, if those services are rendered to the patient for whom the services
are proposed. SB 418 also provides that if a carrier has issued a verification
for proposed medical or health care services, it may not deny or reduce payment
to the physician or provider for those services if they are provided on or
before the expiration date of the verification, which shall not be less than
30 days. The only exception to this guarantee of payment is if the physician
or provider materially misrepresents or substantially fails to perform the
services. SB 418 contains similar requirements for preauthorization, stating
that a carrier that preauthorizes may not deny or reduce payment based on
medical necessity or appropriateness of care, except for the reasons, as previously
stated.
SB 418 also contains provisions regarding the prompt payment of claims
and the availability of coding guidelines and other information through contracts
with preferred provider carriers and HMOs. These provisions are addressed
in emergency rules published elsewhere in this issue of the Texas Register.
Pursuant to SB 418, several provisions became applicable to contracts entered
into or renewed, or certain services provided, on or after the 60th day after
the effective date of the statute, June 17, 2003, rendering those provisions
effective on August 16, 2003. SB 418 further provides that the Commissioner
of Insurance may adopt emergency rules to implement this Act without making
the finding in subsection (a), Section 2001.034, Government Code. An emergency
adoption is warranted so that rules are in place on the effective date of
certain provisions of the statute, to facilitate the uniform implementation
of these sections and to guide affected parties' compliance with the new statutory
requirements. SB 418 requires the commissioner, not later than 90 days after
the Act's effective date, to adopt rules to implement the Act. It also requires
that the commissioner appoint a "technical advisory committee on claims processing"
(TACCP) and to consult with the TACCP with respect to, among other things,
"claims development, submission, processing, adjudication, and payment" before
adopting any rule related to such subjects. Following consultation with the
TACCP, as well as with the Clean Claims Working Group, TDI on July 4, 2003
proposed for public comment rules to implement most of the requirements of
SB 418, and held a public hearing on the rules on August 7, 2003. More than
150 comments were received on the proposal. While the department intends to
adopt final rules in the near future, the usual process of rule adoption and
its associated notice and comment periods, as well as the need to respond
to comments, would have required a timeframe that could not be completed prior
to the date affected entities must begin complying with certain provisions
of the new statute. Considering these facts, it is necessary to adopt these
amendments on an emergency basis to ensure that physicians and providers are
paid timely for their services and to promote regulatory compliance.
The amendments to §19.1703 add new definitions for the terms declination,
preauthorization, preferred provider, and verification. "Declination" is defined
as a response to a request for verification in which a carrier does not issue
a verification for proposed medical care or health care services; however,
the definition makes clear that a declination is not a determination that
a claim resulting from the proposed services may not ultimately be paid. While
the department anticipates carriers will make a good faith effort to respond
to requests for verification, it acknowledges that there may be some instances
where a carrier will not have sufficient information to make a binding determination
in accordance with the terms of the insurance contract or evidence of coverage.
In these instances, the carrier may need to make use of the entire claims
adjudication process provided by SB 418. Under those circumstances, the department
anticipates that carriers will continue to process clean claims in compliance
with all statutory and regulatory requirements, including timely payment.
Accordingly, it is important for physicians and providers, as well as enrollees
and insureds, to understand that a declination of verification should not
in any way hinder the provision of medical or health care services or the
timely payment of claims. In addition, prior to enactment of SB 418, it was
customary for physicians and providers to request and receive patient eligibility
information from carriers. While an eligibility determination from a carrier
was not a guarantee of payment, it still may be a useful option for physicians,
providers and carriers, and nothing in this rule prohibits these parties from
continuing to utilize those processes that are already in place.
Because the existing rule does not contain a definition for "preferred
provider," the adopted amendments to §19.1703 add a definition that applies
to providers that are contracted with HMOs and preferred provider carriers.
They define "preauthorization" as a determination by a carrier that medical
or health care services proposed to be provided are medically necessary and
appropriate.
The adoption defines "verification" as a guarantee by a carrier that it
will pay for proposed medical care or health care services if the services
are rendered within the required timeframe to the patient 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 a carrier to
a physician or provider, if those requests include the information required
by §19.1724(c).
Adopted §19.1723 requires that a carrier that uses a preauthorization
process shall provide to each contracted preferred provider, not later than
the 10th business day after a request is made, a list of medical care and
health care services that require preauthorization, along with information
concerning the preauthorization process. If the proposed services involve
inpatient care, a carrier that approves a request must issue a length of stay
for admission into a health care facility based on the recommendation of the
preferred provider and the carrier's written medically accepted screening
criteria and review procedures.
The adopted section sets forth timeframes in which a carrier must respond
to preauthorization requests for those services requiring preauthorization:
concurrent hospitalization, within 24 hours of receipt; services involving
post-stabilization treatment or life-threatening condition, within the time
appropriate to the circumstances and the condition of the patient, but in
no case to exceed one hour of receipt; and for all other services, not later
than the third calendar day after receipt. A carrier that issues an adverse
determination in response to a post-stabilization or life-threatening condition
treatment must provide the independent review organization notification required
by current §19.1721(c). A carrier that issues any other adverse determination
must comply with current §19.1710 concerning notice of determinations
by utilization review agents.
A carrier must have appropriate personnel reasonably available at a toll-free
telephone number to provide the preauthorization determination during the
hours and days prescribed in the adopted rule. The carrier must also be able
to receive and record calls at other times than the hours specified in the
adopted rule, and respond to those calls within 24 hours. The carrier must
provide a written notification within three days of receipt of request.
A carrier that has preauthorized care or services may not deny or reduce
payment for those services, based on medical necessity or appropriateness
of care, unless the physician or provider has materially misrepresented or
failed to perform the services. The adopted section states that it applies
to an agent or other person with whom a carrier contracts, and provides that
the provisions of the section may not be waived, voided, or nullified by contract.
Adopted §19.1724 requires carriers to be able to receive requests
for verification by telephone, in writing, and by other means, including the
internet, as agreed to by the preferred provider and the HMO or preferred
provider carrier, so long as the agreement does not limit the preferred provider's
option to request a verification by telephone call. It requires carriers to
have appropriate personnel reasonably available at a toll-free telephone number
to accept telephone requests and to provide determinations of previously requested
verifications at the days and hours prescribed in the rule, and to receive
and record calls at all other times and respond not later than two calendar
days after the call is received. The section contains a list of items of information
that must be contained in a request for verification. The department believes
this amount of information is necessary for two reasons. First, because a
carrier that verifies may not deny or reduce payment for a service, verification
will essentially constitute the adjudication of a claim. For that reason,
it is important that the carrier have all necessary information in order to
make this binding determination. Second, the department anticipates that giving
more information to carriers up front will result in more requests for services
receiving verification. The section also allows a carrier, within one day
of a receipt of a request for verification, to make one request to the preferred
provider for additional information that is specific to the request, relevant
and necessary to resolution of the request, and that is in or being incorporated
into the enrollee's medical or billing record.
Adopted §19.1724 contains the following timeframes by which carriers
must respond to a request for verification: for concurrent hospitalizations,
without delay but not later than 24 hours after the request; for post-stabilization
care or life-threatening conditions, without delay but not later than one
hour after the request; for all other requests, without delay, and as appropriate
to the circumstances of the request, but not later than five days after receipt
of the request. The department believes this is consistent with SB 418, which
provides that a carrier must inform a preferred provider "without delay" whether
the service(s) for which verification has been requested will be paid. Because
verification could be requested for a wide variety of services and product
types, some requests will require more processing time than others. As an
example, an HMO claim will be more easily adjudicated than an individual preferred
provider carrier product that has pre-existing condition exclusions. As noted
earlier, access to information will be important in order to allow a carrier
to essentially adjudicate the claim before services are actually rendered.
However, for more easily adjudicated services, the department expects that
a carrier will use only the amount of time necessary to process the request
"without delay" rather than the maximum time frames allowed by the rule.
The rules states that a verification or declination may be delivered by
the carrier via telephone or in writing. If it is delivered via telephone,
the carrier must, within three days of providing a verbal response, provide
a written response that includes the minimum information listed in the rule,
including a statement that the proposed services are being verified or declined
pursuant to this rule. The department believes this procedure is important
because a verification represents a carrier's guarantee that it will not deny
or reduce payment for the services verified; for that reason, it is extremely
important that both the carrier and the physician or provider have a clear
understanding as to what services have been verified. Absence of a means of
confirming what has been requested and verified could result in misunderstandings
and disputes between the parties, which is a situation SB 418 sought to minimize
or eliminate. In addition, the statement identifying the response as a verification
or declination, as defined herein, will distinguish carrier responses pursuant
to this process, versus instances where a carrier may only be providing an
eligibility determination.
In addition to preferred providers, HMOs and preferred provider carriers,
new §19.1724 also applies to a noncontracted physician or provider that
provides care on an emergency basis or on a referral basis where services
are not reasonably available from a network provider. In addition, it states
that the new section's provisions may not be waived, voided, or nullified
by contract.
The amendments and new sections are adopted on an emergency basis
under SB 418, Government Code §2001.034, and Insurance Code Article 3.70-3C,
and §§843.347, 843.348 and 36.001. SB 418 provides that the commissioner
shall adopt rules as necessary to implement that Act, including emergency
adoption of rules pursuant to §2001.034 of the Government Code without
a finding described in subsection (a) of that provision. Government Code §2001.034
provides for the adoption of administrative rules on an emergency basis without
notice and comment. Article 3.70-3C provides for the processes of preauthorization
and verification for preferred provider benefit plans. Sections 843.347 and
843.348 provide for the processes of verification and preauthorization, respectively,
for HMOs. Section 36.001 provides that the Commissioner of Insurance may adopt
any rules necessary and appropriate to implement the powers and duties of
the Texas Department of Insurance under the Insurance Code and other laws
of this state.
§19.1703.Definitions.
The following words and terms, when used in this subchapter, shall
have the following meanings, unless the context clearly indicates otherwise.
(1)
Act--Insurance Code, Article 21.58A, entitled "Health Care
Utilization Review Agents."
(2)
Administrative Procedure Act--Government Code, Chapter
2001.
(3)
Administrator--A person holding a certificate of authority
under the Insurance Code, Article 21.07-6.
(4)
Adverse determination--A determination by a utilization
review agent that the health care services furnished or proposed to be furnished
to a patient are not medically necessary or not appropriate.
(5)
Appeal process--The formal process by which a utilization
review agent offers a mechanism to address adverse determinations.
(6)
Certificate--A certificate of registration granted by the
commissioner to a utilization review agent.
(7)
Commissioner--The commissioner of insurance.
(8)
Complaint--An oral or written expression of dissatisfaction
with a utilization review agent concerning the utilization review agent's
process. A complaint is not a misunderstanding or misinformation that is resolved
promptly by supplying the appropriate information or clearing up the misunderstanding
to the satisfaction of the enrollee.
(9)
Declination--A response to a request for verification in
which an HMO or preferred provider carrier does not issue a verification for
proposed medical care or health care services. A declination is not a determination
that a claim resulting from the proposed services will not ultimately be paid.
(10)
Department--Texas Department of Insurance.
(11)
Dental plan--An insurance policy or health benefit plan,
including a policy written by a company subject to the Insurance Code, Chapter
20, that provides coverage for expenses for dental services.
(12)
Dentist--A licensed doctor of dentistry, holding either
a D.D.S. or a D.M.D. degree.
(13)
Emergency care--Health care services provided in a hospital
emergency facility or comparable facility to evaluate and stabilize medical
conditions of a recent onset and severity, including but not limited to severe
pain, that would lead a prudent layperson possessing an average knowledge
of medicine and health to believe that his or her condition, sickness, or
injury is of such a nature that failure to get immediate medical care could
result in:
(A)
placing the patient's health in serious jeopardy;
(B)
serious impairment to bodily functions;
(C)
serious dysfunction of any bodily organ or part;
(D)
serious disfigurement; or
(E)
in the case of a pregnant woman, serious jeopardy to the
health of the fetus.
(14)
Enrollee--A person covered by a health insurance policy
or health benefit plan. This term includes a person who is covered as an eligible
dependent of another person.
(15)
Health benefit plan--A plan of benefits that defines the
coverage provisions for health care for enrollees offered or provided by any
organization, public or private, other than health insurance.
(16)
Health care provider--Any person, corporation, facility,
or institution licensed by a state to provide or otherwise lawfully providing
health care services that is eligible for independent reimbursement for those
services.
(17)
Health insurance policy--An insurance policy, including
a policy written by a company subject to the Insurance Code, Chapter 20, that
provides coverage for medical or surgical expenses incurred as a result of
accident or sickness.
(18)
Inquiry--A request for information or assistance from
a utilization review agent.
(19)
Life-threatening--A disease or condition for which the
likelihood of death is probable unless the course of the disease or condition
is interrupted.
(20)
Mental health medical record summary--A summary of process
or progress notes relevant to understanding the patient's need for treatment
of a mental or emotional condition or disorder such as:
(A)
identifying information; and
(B)
a treatment plan that includes:
(i)
diagnosis;
(ii)
treatment intervention;
(iii)
general characterization of patient behaviors or thought
processes that affect level of care needs; and
(iv)
discharge plan.
(21)
Mental health therapist--Any of the following persons
who, in the ordinary course of business or professional practice, diagnose,
evaluate, or treat any mental or emotional condition or disorder:
(A)
a person licensed by the Texas State Board of Medical Examiners
to practice medicine in this state;
(B)
a person licensed as a psychologist by the Texas State
Board of Examiners of Psychologists;
(C)
a person licensed as a psychological associate by the Texas
State Board of Examiners of Psychologists;
(D)
a person licensed as a specialist in school psychology
by the Texas State Board of Examiners of Psychologists;
(E)
a person licensed as a marriage and family therapist by
the Texas State Board of Examiners of Marriage and Family Therapists;
(F)
a person licensed as a professional counselor by the Texas
State Board of Examiners of Professional Counselors;
(G)
a person licensed as a chemical dependency counselor by
the Texas Commission on Alcohol and Drug Abuse;
(H)
a person licensed as an advanced clinical practitioner
by the Texas State Board of Social Worker Examiners;
(I)
a person licensed as a master social worker by the Texas
State Board of Social Worker Examiners;
(J)
a person licensed as a social worker by the Texas State
Board of Social Worker Examiners;
(K)
a person licensed as a physician assistant by the Texas
State Board of Physician Assistant Examiners;
(L)
a person licensed as a registered professional nurse by
the Texas Board of Nurse Examiners;
(M)
a person licensed as a vocational nurse by the Texas Board
of Vocational Nurse Examiners;
(N)
any other person who is licensed or certified by a state
licensing board in the State of Texas to diagnose, evaluate, or treat any
mental or emotional condition or disorder.
(22)
Mental or emotional condition or disorder--A mental or
emotional illness as detailed in the most current revision of the Diagnostic
and Statistical Manual of Mental Disorders.
(23)
Nurse--A registered professional nurse, a licensed vocational
nurse, or a licensed practical nurse.
(24)
Open records law--Government Code, Chapter 552.
(25)
Patient--An enrollee or an eligible dependent of the enrollee
under a health benefit plan or health insurance plan.
(26)
Payor--An insurer writing health insurance policies; any
preferred provider organization, health maintenance organization, self-insurance
plan; or any other person or entity which provides, offers to provide, or
administers hospital, outpatient, medical, or other health benefits to persons
treated by a health care provider in this state pursuant to any policy, plan
or contract.
(27)
Person--An individual, a corporation, a partnership, an
association, a joint stock company, a trust, an unincorporated organization,
any similar entity or any combination of the foregoing acting in concert.
(28)
Physician--A licensed doctor of medicine or a doctor of
osteopathy.
(29)
Preauthorization--A determination by an HMO or preferred
provider carrier that medical care or health care services proposed to be
provided to an enrollee are medically necessary and appropriate.
(30)
Preferred provider--
(A)
with regard to a preferred provider carrier, a preferred
provider as defined by Insurance Code Article 3.70-3C, §1(10) (Preferred
Provider Benefit Plans) or Article 3.70-3C, §1(1) (Use of Advanced Practice
Nurses and Physician Assistants by Preferred Provider Plans).
(B)
with regard to an HMO,
(i)
a physician, as defined by Insurance Code Section 843.002(22),
who is a member of that HMO's delivery network; or
(ii)
a provider, as defined by Insurance Code Section 843.002(24),
who is a member of that HMO's delivery network.
(31)
Provider of record--The physician or other health care
provider that has primary responsibility for the care, treatment, and services
rendered to the enrollee or the physician or health care provider that is
requesting or proposing to provide the care, treatment and services to the
enrollee and includes any health care facility when treatment is rendered
on an inpatient or outpatient basis.
(32)
Retrospective review--A system in which review of the
medical necessity and appropriateness of health care services provided to
an enrollee is performed for the first time subsequent to the completion of
such health care services. Retrospective review does not include subsequent
review of services for which prospective or concurrent reviews for medical
necessity and appropriateness were previously conducted.
(33)
Screening criteria--The written policies, decision rules,
medical protocols, or guides used by the utilization review agent as part
of the utilization review process (e.g., appropriateness evaluation protocol
(AEP) and intensity of service, severity of illness, discharge, and appropriateness
screens (ISD-A)).
(34)
Utilization review--A system for prospective or concurrent
review of the medical necessity and appropriateness of health care services
being provided or proposed to be provided to an individual within the state.
Utilization review shall not include elective requests for clarification of
coverage.
(35)
Utilization review agent--An entity that conducts utilization
review, for an employer with employees in this state who are covered under
a health benefit plan or health insurance policy, a payor, or an administrator.
(36)
Utilization review plan--The screening criteria and utilization
review procedures of a utilization review agent.
(37)
Verification--A guarantee by an HMO or preferred provider
carrier that the HMO or preferred provider carrier will pay for proposed medical
care or health care services if the services are rendered within the required
timeframe to the patient 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 carrier
to a physician or provider if the request for the pre-certification, certification,
re-certification, or representation includes the requirements of §19.1724(c)
of this title (relating to Verification).
(38)
Working day--A weekday, excluding New Years Day, Memorial
Day, Fourth of July, Labor Day, Thanksgiving Day, and Christmas Day.
§19.1723.Preauthorization.
(a)
An HMO or preferred provider carrier that requires preauthorization
as a condition of payment to a preferred provider shall comply with the procedures
of this section for determinations of medical necessity for those services
the HMO or preferred provider carrier identifies in accordance with subsection
(b) of this section.
(b)
An HMO or preferred provider carrier that uses a preauthorization
process for medical care and health care services shall provide to each contracted
preferred provider, not later than the 10th business 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.
(c)
If the proposed medical care or health care services involve
inpatient care, the HMO or preferred provider carrier shall review the request
and, if approved, issue a length of stay for the admission into a health care
facility based on the recommendation of the patient's preferred provider and
the HMO or preferred provider carrier's written medically accepted screening
criteria and review procedures.
(d)
On receipt of a preauthorization request from a preferred
provider for proposed services that require preauthorization, the HMO or preferred
provider carrier shall issue and transmit a determination indicating whether
the proposed medical or health care services are preauthorized. An HMO or
preferred provider carrier shall respond to a request for preauthorization
within the following time periods:
(1)
For services not included under paragraphs (2) and (3)
of this subsection, the 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 carrier.
(2)
If the proposed medical or health care services are for
concurrent hospitalization care, the HMO or preferred provider carrier shall
issue and transmit a determination indicating whether proposed services are
preauthorized within 24 hours of receipt of the request.
(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 carrier
shall 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 patient, but in no
case to exceed one hour from receipt of the request. In such circumstances,
the determination shall be provided to the treating physician or health care
provider. If the HMO or preferred provider carrier 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
carrier shall provide to the enrollee or person acting on behalf of the enrollee,
and the enrollee's provider of record, the notification required by §19.1721(c)
of this title (relating to Independent Review of Adverse Determinations).
(e)
A preferred provider may inquire via telephone as to the
HMO or preferred provider carrier's preauthorization determination. An HMO
or preferred provider carrier shall have appropriate personnel as described
in §19.1706 of this title (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 carrier must have
a telephone system capable of accepting or recording incoming inquiries after
6:00 p.m. central time Monday through Friday and after noon central time on
Saturday, Sunday, and legal holidays and responding to each of those calls
not later than 24 hours after the call is received. An HMO or preferred provider
carrier providing a determination under this subsection shall, within three
calendar days of receipt of the request, provide a written notification to
the preferred provider.
(f)
If an HMO or preferred provider carrier has preauthorized
medical care or health care services, the HMO or preferred provider carrier
may not deny or reduce payment to the physician or provider for those services
based on medical necessity or appropriateness 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.
(g)
If an HMO or preferred provider carrier issues an adverse
determination in response to a request made under subsection (d) of this section,
a notice consistent with the provisions of §19.1710(c) of this title
(relating to Notice of Determinations Made by Utilization Review Agents) shall
be provided to the enrollee, a person acting on behalf of the enrollee, or
the enrollee's provider of record. An enrollee may appeal any adverse determination
in accordance with §19.1712 of this title (relating to Appeal of Adverse
Determination of Utilization Review Agents).
(h)
This section applies to an agent or other person with whom
an HMO or preferred provider carrier contracts to perform, or to whom the
HMO or preferred provider carrier 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 carrier's
responsibility to comply with all statutory and regulatory requirements.
(i)
The provisions of this section may not be waived, voided,
or nullified by contract.
§19.1724.Verification.
(a)
The provisions of this section apply to
(1)
HMOs;
(2)
preferred provider carriers;
(3)
preferred providers; and
(4)
physicians or healthcare providers that provide to an enrollee
of an HMO or preferred provider carrier:
(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 carrier, or a preferred provider
because the services are not reasonably available from a preferred provider
who is included in the HMO or preferred provider carrier's network.
(b)
An HMO or preferred provider carrier 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 carrier, provided
that such agreement may not limit the preferred provider's option to request
a verification by telephone call.
(c)
An HMO or preferred provider carrier shall have appropriate
personnel reasonably available at a toll-free telephone number to accept telephone
requests for verification and to provide determinations of previously requested
verifications 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 carrier must have a telephone system capable of accepting or recording
incoming inquiries after 6:00 p.m. central time Monday through Friday and
after noon central time on Saturday, Sunday, and legal holidays and responding
to each of those calls not later than two calendar days after the call is
received.
(d)
Any request for verification shall contain the following
information:
(1)
patient name;
(2)
patient ID number, if included on an identification card
issued by the HMO or preferred provider carrier;
(3)
patient date of birth;
(4)
name of enrollee or subscriber, if included on an identification
card issued by the HMO or preferred provider carrier;
(5)
patient relationship to enrollee or subscriber;
(6)
presumptive diagnosis, if known, otherwise presenting symptoms;
(7)
description of proposed procedure(s) or procedure code(s);
(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 carrier;
(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 carrier may, within one day of
receipt of the 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 carrier may make only one request for additional
information from the requesting preferred provider under this section.
(g)
A request for information under subsection (e) 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, the HMO or preferred provider carrier shall issue a verification
or declination. An HMO or preferred provider carrier shall respond to requests
for verification within the following time periods.
(1)
Except as provided in paragraph (2) of this subsection,
an HMO or preferred provider carrier shall provide a verification or declination
in response to a request for verification without delay, and as appropriate
to the circumstances the particular request, but not later than five days
after the date of receipt of the request for verification.
(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 carrier received the
request.
(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
carrier received the request.
(i)
A verification or declination may be delivered via telephone
call or in writing. If the verification or declination is delivered via telephone
call, the HMO or preferred provider carrier shall, 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 shall not be less than 30 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)
if the request involved services for which preauthorization
is required, a decision as to whether the proposed services are medically
necessary and appropriate, as required in §19.1723 of this title (relating
to Preauthorization);
(10)
a unique verification number that allows the HMO or preferred
provider carrier to match the verification and subsequent claims related to
the proposed service; and
(11)
a statement that the proposed services are being verified
or declined pursuant to Title 28 Texas Administrative Code §19.1724.
(j)
An HMO or preferred provider carrier that issues a verification
may not deny or otherwise reduce payment to the preferred provider for those
medical care or health care services if provided on or before the expiration
date for the verification, which shall not be less than 30 days, unless the
preferred provider has materially misrepresented the proposed medical or health
care services or has substantially failed to perform the medical or health
care services as verified.
(k)
The provisions of this section may not be waived, voided,
or nullified by contract.
This agency hereby certifies that the emergency adoption
has been reviewed by legal counsel and found to be within the agency's legal
authority to adopt.
Filed with the Office of
the Secretary of State on August 15, 2003.
TRD-200305225
Gene C. Jarmon
General Counsel and Chief Clerk
Texas Department of Insurance
Effective Date: August 16, 2003
Expiration Date: December 14, 2003
For further information, please call: (512) 463-6327
Subchapter T. SUBMISSION OF CLEAN CLAIMS
Chapter 11.
HEALTH MAINTENANCE ORGANIZATIONS
Chapter 19.
AGENTS' LICENSING
Chapter 21.
TRADE PRACTICES