• Increase Text Icon
  • Decrease Text Icon
  • Email Icon
  • Print this page
You are here: Home . rules . 2003 . 0815C-059
Archived File – for Reference Use.
Links and contact information may be outdated.

Subchapter R. Utilization Review Agents

28 TAC §§19.1703, 19.1723, and 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) (78 th 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 necess ity 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 60 th 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 pr omote 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 10 th 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.



For more information, contact:

Contact Information and Other Helpful Links