Texas § IN.4201.655 - DENIAL OR RESCISSION OF PREAUTHORIZATION EXEMPTION

§ IN.4201.655. DENIAL OR RESCISSION OF PREAUTHORIZATION EXEMPTION

DENIAL OR RESCISSION OF PREAUTHORIZATION EXEMPTION. (a) A health maintenance organization or insurer may rescind an exemption from preauthorization requirements under Section 4201.653 only: (1) during January of a year beginning on or after the first anniversary of the last day of the most recent evaluation period for the exemption; (2) if the health maintenance organization or insurer makes a determination, on the basis of a retrospective review of a random sample of not fewer than five and no more than 20 claims submitted by the physician or provider during the most recent evaluation period described by Section 4201.653 (b), that less than 90 percent of the claims for the particular health care service met the medical necessity criteria that would have been used by the health maintenance organization or insurer when conducting preauthorization review for the particular health care service during the relevant evaluation period; and (3) if the health maintenance organization or insurer complies with other applicable requirements specified in this section, including: (A) notifying the physician or provider not less than 25 days before the proposed rescission is to take effect; and (B) providing with the notice under Paragraph (A): (i) the sample information used to make the determination under Subdivision (2); and (ii) a plain language explanation of how the physician or provider may appeal and seek an independent review of the determination. (b) A determination made under Subsection (a)(2) must be made by an individual licensed to practice medicine in this state. For a determination made under Subsection (a)(2) with respect to a physician, the determination must be made by an individual licensed to practice medicine in this state who has the same or similar specialty as that physician. The reviewing physician may not hold a license to practice administrative medicine under Section 155.009 , Occupations Code. (b-1) Notwithstanding Subsection (a)(2), if there are fewer than five claims submitted by the physician or provider during the most recent evaluation period described by Section 4201.653 (b) for a particular health care service, the health maintenance organization or insurer shall review all the claims submitted by the physician or provider during the most recent evaluation period for that service. (c) A health maintenance organization or insurer may deny an exemption from preauthorization requirements under Section 4201.653 only if: (1) the physician or provider does not have the exemption at the time of the relevant evaluation period; and (2) the health maintenance organization or insurer provides the physician or provider with actual statistics and data for the relevant preauthorization request evaluation period and detailed information sufficient to demonstrate that the physician or provider does not meet the criteria for an exemption from preauthorization requirements for the particular health care service under Section 4201.653 . Added by Acts 2021, 87th Leg., R.S., Ch. 1018 (H.B. 3459 ), Sec. 5, eff. September 1, 2021. Amended by: Acts 2025, 89th Leg., R.S., Ch. 640 (H.B. 3812 ), Sec. 4, eff. September 1, 2025.