Section 21.3104 - Training(a) In this section, "preauthorization" has the meaning assigned by Insurance Code § 1352.004(a), and includes benefit determinations for proposed medical or health care services.(b) Each issuer must develop written preauthorization and utilization review policies and procedures for the purpose of identifying services to be covered for acquired brain injury, to be used by any individual responsible for preauthorization of coverage or utilization review. Such policies and procedures must include: (1) identification of all current Common Procedural Terminology (CPT) codes associated with services for acquired brain injury; and(2) a means to identify an enrollee initially diagnosed with an acquired brain injury.(c) Each health benefit plan issuer must ensure that all employees or staff responsible for preauthorization of coverage or utilization review, or any individual performing these processes, receive training to prevent wrongful denial of coverage required under Insurance Code Chapter 1352 and this subchapter, and to avoid confusion of medical and surgical benefits with mental and behavioral health benefits. At a minimum, training must consist of: (1) identification of services likely to be requested in treating an enrollee with an acquired brain injury;(2) identification of specific therapies currently used in treating an enrollee with an acquired brain injury;(3) instruction relating to correctly evaluating requests for services to differentiate between covered medical and surgical benefits versus covered benefits for mental and behavioral health; and(4) instruction relating to the requirements of Insurance Code Chapter 1352 and this subchapter.(d) At a minimum, training must be accomplished by attendance at an initial orientation, in-service, or continuing education program relating to acquired brain injuries and their treatments, provided that the training is consistent with the requirements of subsections (a) and (b) of this section. (1) Documentation and verification of training must be maintained for each employee or staff member responsible for preauthorization of coverage, utilization review, or any individual performing these processes.(2) On request, any documentation and verification required by paragraph (1) of this subsection must be provided to the issuer with whom the employee, staff member, or individual is employed or contracted.(3) On request, any documentation and verification required by paragraph (1) of this subsection must be provided to the department for review.(e) The requirements of this section also apply to any contracted entity of an issuer to the extent the contracted entity is responsible for preauthorization or utilization review.28 Tex. Admin. Code § 21.3104
The provisions of this §21.3104 adopted to be effective August 26, 2002, 27 TexReg 7814; amended to be effective February 23, 2009, 34 TexReg 1247; Amended by Texas Register, Volume 40, Number 22, May 29, 2015, TexReg 3179, eff. 6/7/2015