28 Tex. Admin. Code § 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.
Notes
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