Tex. Ins. Code Section 1301.135
Preauthorization of Medical and Health Care Services


(a)

An insurer that uses a preauthorization process for medical care or health care services shall provide to each preferred provider, not later than the fifth business day after the date a request is made, a list of medical care and health care services that require preauthorization and information concerning the preauthorization process.

(b)

If proposed medical care or health care services require preauthorization as a condition of the insurer’s payment to a preferred provider under a health insurance policy, the insurer shall determine whether the medical care or health care services proposed to be provided to the insured are medically necessary and appropriate.

(c)

On receipt of a request from a preferred provider for preauthorization, the insurer shall review and issue a determination indicating whether the proposed medical care or health care services are preauthorized. The determination must be issued and transmitted not later than the third calendar day after the date the request is received by the insurer.

(d)

If the proposed medical care or health care services involve inpatient care and the insurer requires preauthorization as a condition of payment, the insurer shall review the request and issue a length of stay for the admission into a health care facility based on the recommendation of the patient’s physician or health care provider and the insurer’s written medically accepted screening criteria and review procedures. If the proposed medical or health care services are to be provided to a patient who is an inpatient in a health care facility at the time the services are proposed, the insurer shall review the request and issue a determination indicating whether proposed services are preauthorized within 24 hours of the request by the physician or provider.

(e)

An insurer shall have appropriate personnel reasonably available at a toll-free telephone number to respond to requests for a preauthorization between 6 a.m. and 6 p.m. central time Monday through Friday on each day that is not a legal holiday and between 9 a.m. and noon central time on Saturday, Sunday, and legal holidays. An insurer must have a telephone system capable of accepting or recording incoming phone calls for preauthorizations after 6 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.

(f)

If an insurer has preauthorized medical care or health care services, the insurer may not deny or reduce payment to the physician or health care 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 proposed medical or health care services.

(g)

This section applies to an agent or other person with whom an insurer contracts to perform, or to whom the insurer delegates the performance of, preauthorization of proposed medical or health care services.

(h)

The provisions of this section may not be waived, voided, or nullified by contract.
Added by Acts 2005, 79th Leg., Ch. 728 (H.B. 2018), Sec. 11.037(b), eff. September 1, 2005.
Amended by:
Acts 2019, 86th Leg., R.S., Ch. 1218 (S.B. 1742), Sec. 2.03, eff. September 1, 2019.

Source: Section 1301.135 — Preauthorization of Medical and Health Care Services, https://statutes.­capitol.­texas.­gov/Docs/IN/htm/IN.­1301.­htm#1301.­135 (accessed Mar. 23, 2024).

1301.001
Definitions
1301.002
Nonapplicability to Dental Care Benefits
1301.003
Preferred Provider Benefit Plans and Exclusive Provider Benefit Plans Permitted
1301.005
Availability of Preferred Providers
1301.006
Availability of and Accessibility to Health Care Services
1301.007
Rules
1301.008
Conflict with Other Law
1301.009
Annual Report
1301.010
Balance Billing Prohibition Notice
1301.0041
Applicability
1301.0042
Applicability of Insurance Law
1301.0045
Construction of Chapter
1301.0046
Coinsurance Requirements for Services of Nonpreferred Providers
1301.051
Designation as Preferred Provider
1301.0051
Exclusive Provider Benefit Plans: Quality Improvement and Utilization Management
1301.0052
Exclusive Provider Benefit Plans: Referrals for Medically Necessary Services
1301.052
Designation of Advanced Practice Nurse or Physician Assistant as Preferred Provider
1301.0053
Exclusive Provider Benefit Plans: Emergency Care
1301.053
Appeal Relating to Designation as Preferred Provider
1301.054
Notice to Practitioners of Preferred Provider Benefit Plan
1301.0055
Network Adequacy Standards
1301.055
Complaint Resolution
1301.0056
Examinations and Fees
1301.056
Restrictions on Payment and Reimbursement
1301.0057
Access to Out-of-network Providers
1301.057
Termination of Participation
1301.058
Economic Profiling
1301.0058
Protected Communications by Preferred Providers
1301.059
Quality Assessment
1301.060
Compensation on Discounted Fee Basis
1301.0061
Terms of Enrollee Eligibility
1301.061
Preferred Provider Networks
1301.062
Preferred Provider Contracts Between Insurers and Podiatrists
1301.063
Contract Provisions Relating to Use of Hospitalist
1301.064
Contract Provisions Relating to Payment of Claims
1301.065
Shifting of Insurer’s Tort Liability Prohibited
1301.066
Retaliation Against Preferred Provider Prohibited
1301.067
Interference with Relationship Between Patient and Physician or Health Care Provider Prohibited
1301.068
Inducement to Limit Medically Necessary Services Prohibited
1301.069
Services Provided by Certain Physicians and Health Care Providers
1301.101
Definition
1301.102
Submission of Claim
1301.103
Deadline for Action on Clean Claims
1301.104
Deadline for Action on Pharmacy Claims
1301.105
Audited Claims
1301.106
Claims Processing Procedures and Claims Payment Processes
1301.107
Contractual Waiver and Other Actions Prohibited
1301.108
Attorney’s Fees
1301.109
Applicability to Entities Contracting with Insurer
1301.131
Elements of Clean Claim
1301.132
Overpayment
1301.133
Verification
1301.134
Coordination of Payment
1301.135
Preauthorization of Medical and Health Care Services
1301.136
Availability of Coding Guidelines
1301.137
Violation of Claims Payment Requirements
1301.138
Applicability to Entities Contracting with Insurer
1301.139
Legislative Declaration
1301.140
Out-of-pocket Expense Credit
1301.151
Insured’s Right to Treatment
1301.152
Continuing Care in General
1301.153
Continuity of Care
1301.154
Obligation for Continuity of Care of Insurer
1301.155
Emergency Care
1301.156
Payment of Claims to Insured
1301.157
Plain Language Requirements
1301.158
Information Concerning Preferred Provider Benefit Plans
1301.159
Annual List of Preferred Providers
1301.160
Notification of Termination of Participation of Preferred Provider
1301.161
Retaliation Against Insured Prohibited
1301.162
Identification Card
1301.163
Applicability of Subchapter to Entities Contracting with Insurer
1301.164
Out-of-network Facility-based Providers
1301.165
Out-of-network Diagnostic Imaging Provider or Laboratory Service Provider
1301.166
Out-of-network Emergency Medical Services Provider
1301.201
Contracts with and Reimbursement for Nurse First Assistants
1301.202
Contracts with Hospitals
1301.0515
Acupuncturist Services
1301.0516
Chiropractic Services
1301.0521
Designation of Certain Podiatrists as Preferred Providers
1301.0522
Designation of Certain Optometrists, Therapeutic Optometrists, and Ophthalmologists as Preferred Providers
1301.00553
Maximum Travel Time and Distance Standards by Preferred Provider Type
1301.00554
Other Maximum Distance Standard Requirements
1301.00555
Maximum Appointment Wait Time Standards
1301.00565
Public Hearing on Network Adequacy Standards Waivers
1301.00566
Effect of Network Adequacy Standards Waiver on Balance Billing Prohibitions
1301.0625
Health Care Collaboratives
1301.0641
Contract Provisions Prohibiting Rejection of Batched Claims
1301.0642
Contract Provisions Allowing Certain Adverse Material Changes Prohibited
1301.1021
Receipt of Claim
1301.1051
Completion of Audit
1301.1052
Preferred Provider Appeal After Audit
1301.1053
Deadlines Not Extended
1301.1054
Requests for Additional Information
1301.1351
Posting of Preauthorization Requirements
1301.1352
Changes to Preauthorization Requirements
1301.1353
Remedy for Noncompliance
1301.1581
Information Concerning Exclusive Provider Benefit Plans
1301.1591
Preferred Provider Information on Internet

Accessed:
Mar. 23, 2024

§ 1301.135’s source at texas​.gov