28 Tex. Admin. Code § 21.2425 - Claims and Utilization Review: Reporting Classifications
(a) Separate reporting. Within the "MH/SUD
Parity Rule Division 2 Data Collection Reporting Form" template, in the
worksheet titled "Claims and Utilization Review," an issuer must separately
report claims and requests for utilization review for medical/surgical and
MH/SUD.
(b) ICD diagnosis codes. In
the worksheet titled "Claims and Utilization Review," all claims and
utilization review requests with mental, behavioral, and neurodevelopmental
disorder diagnosis codes in the International Classification of Diseases and
Related Health Problems should be categorized as MH/SUD. Claims and utilization
review requests with all other ICD diagnostic codes should be categorized as
medical/surgical.
(c) Reporting
classifications. Claims and requests for utilization review are to be
identified in the worksheet as belonging in one the following reporting
classifications:
(1) inpatient,
in-network;
(2) inpatient,
out-of-network;
(3) outpatient,
in-network, consisting of:
(A) office visits;
and
(B) all other;
(4) outpatient, out-of-network,
consisting of:
(A) office visits;
and
(B) all other;
(5) emergency; and
(6) prescription drugs.
(d) Unneeded information. Where appropriate,
an issuer may enter "N/A" in the worksheet. For example, indemnity plans will
not have data for in-network classifications, and HMOs with no POS component
and EPOs will not have data for out-of-network classifications. An issuer of
those plans may therefore enter N/A where that data is requested.
Notes
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