Section 19.1730 - DefinitionsThe following words and terms have the following meanings when used in this subchapter unless the context clearly indicates otherwise.
(1) Adverse determination regarding a preauthorization exemption--A decision by an issuer that one or more claims retrospectively reviewed as part of an evaluation as defined in paragraph (4)(B) of this section, with respect to a particular health care service for which the physician or provider has a preauthorization exemption, did not meet the issuer's screening criteria, and leads to an issuer's decision to rescind a preauthorization exemption. An adverse determination regarding a preauthorization exemption is not an adverse determination as defined under § 19.1703 of this title (relating to Definitions).(2) Denial of preauthorization exemption--A determination that a physician or provider does not qualify for a preauthorization exemption based on the issuer conducting an evaluation, as defined in paragraph (4)(A) of this section, of eligible preauthorization requests and demonstrating that the physician or provider received approval for fewer than 90% of the eligible preauthorization requests made for a particular health care service during the most recent evaluation period.(3) Eligible preauthorization request--A preauthorization request for a particular health care service is eligible for the purposes of an evaluation under paragraph (4)(A) of this section if it is submitted by the physician or provider and finalized by the health plan during the evaluation period, is not pending appeal, and has an outcome of either approving the particular health care service or issuing an adverse determination for the particular health care service. A preauthorization request that is modified with the acceptance of the physician or provider and approved by the plan as modified is an eligible preauthorization request for the purpose of conducting an evaluation under this section, with respect to the particular health care service that was approved. If a preauthorization request includes more than one particular health care service, the outcome for each service must be counted separately for the purposes of an evaluation.(4) Evaluation-- (A) with respect to a particular health care service for which a physician or provider does not have a preauthorization exemption, a review of the outcomes of eligible preauthorization requests submitted by the physician or provider during the most recent evaluation period to determine the percentage of requests that were approved, which is conducted for the purpose of evaluating whether to grant or deny a preauthorization exemption; or(B) with respect to a particular health care service for which a physician or provider has a preauthorization exemption, a retrospective review of a random sample of payable claims submitted by or in connection with the physician or provider during the most recent evaluation period to determine the percentage of claims that would have been approved, based on meeting the issuer's applicable medical necessity criteria at the time the service was provided, which is conducted for the purpose of evaluating whether to continue or rescind a preauthorization exemption and consistent with Insurance Code § 4201.655, concerning Denial or Rescission of Preauthorization Exemption.(5) Evaluation period--The six-month period preceding an evaluation. The evaluation periods are as follows: (A) for an initial determination of a preauthorization exemption grant or denial, the evaluation period is the six-month period that begins on January 1, 2022, or the subsequent six-month periods of July 1 - December 31 and January 1 - June 30 that follow each year;(B) after a denial or rescission of a preauthorization exemption for a particular health care service, the subsequent six-month evaluation period begins on the first day following the end of the evaluation period that formed the basis of the denial or rescission; and(C) for a notification of a preauthorization exemption rescission as provided in Insurance Code § 4201.655(a), the evaluation period is the six-month period an issuer determines or the subsequent six-month periods that follow, but there may not be more than two months between an evaluation period ending and the provision of notice under § 19.1732 of this title (relating to Notice of Preauthorization Exemption Grants, Denials, or Rescissions).(6) Issuer--A health maintenance organization or insurer that is subject to Insurance Code Chapter 4201, Subchapter N, including a URA or a person who contracts with an issuer to issue a preauthorization determination, or performs the functions described in this division.(7) Particular health care service--A health care service, including a prescription drug, that is subject to preauthorization as listed on the issuer's website under § 19.1718(j) of this title (relating to Preauthorization for Health Maintenance Organizations and Preferred Provider Benefit Plans).(8) Physician--Has the meaning assigned by Insurance Code § 843.002, concerning Definitions.(9) Preauthorization--Has the meaning assigned in Insurance Code § 4201.651, concerning Definitions. "Preauthorization" under this division does not include concurrent utilization review.(10) Preauthorization exemption--A privilege obtained under this division in which a physician or provider is not subject to a preauthorization requirement that otherwise applies with respect to a particular health care service. The preauthorization exemption applies both to care rendered by a treating physician or provider and to care ordered by a physician or provider who is acting in his or her capacity as a treating physician or provider.(11) Provider--Has the meaning assigned by Insurance Code § 843.002.(12) Random sample--A collection of at least five but no more than 20 claims for a particular health care service, selected without method or conscious decision, for the purpose of evaluating a physician's or provider's continued eligibility for a preauthorization exemption.(13) Rescission of preauthorization exemption--An adverse determination regarding a preauthorization exemption based on an evaluation, as defined in paragraph (4)(B) of this section and consistent with Insurance Code § 4201.655(b), in which the issuer would have fully approved fewer than 90% of claims for a particular health care service.(14) Treating physician or provider--The physician or other provider who is primarily responsible for a patient's health and medical care. A "treating physician or provider" can include a rendering physician or provider or a referring or ordering physician or provider.28 Tex. Admin. Code § 19.1730
Adopted by Texas Register, Volume 47, Number 34, August 26, 2022, TexReg 5135, eff. 9/1/2022