ModifiedBaylor Scott & White Health PlanPolicy N/A

Preauthorization Exemptions (Implementation of HB 3459)

Governs Texas Department of Insurance rules implementing HB 3459 about when issuers may grant, deny, or rescind preauthorization exemptions for physicians and providers making preauthorization requests; affects issuers, physicians, providers, and utilization review agents operating in Texas.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyPreauthorization Exemptions (HB 3459 implementation)

Policy CodePolicy N/A

Change TypeMaterial revisions and clarifications to definitions, thresholds, notices, and appeals

Effective DateN/A

Next Review DateN/A

Key ActionEnsure claims include the ordering provider name and NPI in the specified claim fields so preauthorization exemptions can be applied.

SourceLink

POLICY UPDATE CHANGES

New Division 2 (§§19.1730 - 19.1733) establishing preauthorization exemption rules was adopted to implement HB 3459.

Minimum threshold for eligible preauthorization requests for evaluation reduced from 20 to five.

Definition changes clarify that 'eligible preauthorization request' and 'evaluation' refer to retrospective review of a random sample and count approved or adverse determinations per eligible request.

Issuers must give notice within five days of completing an evaluation and include plain-language explanation and coding guidance in exemption notices.

The term 'full and final approval' was replaced with 'eligible' in the definition of 'denial of preauthorization exemption' and 'evaluation' language was updated to reference 'eligible preauthorization requests.'

The definition of 'evaluation' was clarified to require retrospective review of a random sample for rescission determinations and tied to Insurance Code §4201.655.

Subsection added requiring claims to include ordering physician/provider name and NPI in claim fields (CMS 1500 Box 17/17B, UB-04 fields 76-79 or corresponding electronic fields) so exemptions can be applied.

Minimum threshold to qualify for an initial preauthorization exemption was reduced from 20 requests to five eligible preauthorization requests during the evaluation period.

TDI clarified that 'particular health care service' can include pharmaceutical services and prescription drugs under Insurance Code definitions and declined to narrowly limit the term.

Definition of 'treating physician or provider' broadened to 'health and medical care' and explicitly includes an 'ordering' physician or provider.

TDI confirmed rescission determinations must be based on a random sample and incorporated statutory requirements by reference rather than restating them in full.

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5minimum eligible requests for evaluation

5 daysissuer notice after evaluation

6 monthsminimum exemption duration

30 daysprovider time to supply records

≤20max sample size for review

90%approval threshold to avoid rescission

Preauthorization Exemption Coverage Criteria

inv-01: Preauthorization exemption criteria

Criteria and process for initial exemptions, rescissions, notices, and appeals.

Evaluation for an initial preauthorization exemption must be conducted by issuer using the physician or provider's NPI to identify the provider.

The issuer must review the outcomes of no fewer than five eligible preauthorization requests for a particular health care service during the evaluation period to determine whether the physician or provider qualifies for an exemption.

If a physician or provider has a preauthorization exemption, the issuer may conduct a retrospective evaluation based on a random sample of payable claims (minimum 5, maximum 20) to determine whether to rescind the exemption consistent with Insurance Code §4201.655.

Issuers must provide notice to the physician or provider when granting, denying, or rescinding a preauthorization exemption, and must provide the notice within five days after completing an evaluation.

Rescission notices must be provided during the months required by Insurance Code §4201.655 and must include the date the notice is issued, the effective date of rescission, an explanation of appeal and independent review rights, the total number of eligible payable claims, identification of each claim in the random sample, the issuer's determination for each sample claim, the principal reasons and clinical basis for adverse determinations, the specialty of the determining professional, and instructions for submitting records and appeal forms (including sample form LHL011).

A physician or provider may request independent review of a rescission by submitting the issuer's form and, when the rescission was based on failure to provide records, must include applicable medical records with the independent review request.

If the rescission notice identifies at least five additional eligible claims not included in the original sample, the provider may request the IRO review another random sample; the issuer must provide a listing of all eligible claims not included in the original sample to support that request.

inv-02: Preauthorization exemption criteria and evaluation rules

Conditions for granting and maintaining a preauthorization exemption for a particular health care service:

Minimum evidence threshold: A physician or provider must have at least five eligible preauthorization requests for the particular health care service submitted and finalized during the evaluation period to be evaluated for an exemption.

Initial evaluations are based on preauthorization requests submitted by the physician or provider (not claims) and the exemption is awarded to the physician or provider who made the preauthorization requests.

Claim identification requirement: To rely on an exemption when care ordered by an exempt provider is rendered by another provider, the claim must include the ordering physician or provider's name and NPI in CMS Form 1500 fields 17/17B, UB-04 fields 76-79, or corresponding electronic ASC X12N 837 ordering/attending fields; absent this information, issuer may treat the claim as subject to preauthorization.

Rescission sampling rule: Rescission determinations must be based on a retrospective review of a random sample of payable claims of at least five and no more than 20 claims for the particular health care service.

inv-03: Preauthorization exemption criteria and procedures

Criteria and procedural rules governing exemption initial evaluation, continued eligibility, rescission, and related notices and appeals.

Initial evaluation requirements: The issuer must evaluate all preauthorization requests submitted and finalized by the physician or provider during the most recent evaluation period; at least five eligible preauthorization requests are required for the evaluation to proceed; initial evaluations do not include claims data.

Granting criteria: To qualify for an exemption, the physician or provider must meet the statutory clinical criteria (including meeting medical guidelines in at least 90% of cases) over the evaluation period as reflected in eligible preauthorization request outcomes.

Continued eligibility monitoring: Continued eligibility for an exemption is determined by retrospective review of payable claims submitted by or in connection with the physician or provider for the particular health care service; issuers must ensure systems allow capturing ordering provider identifiers on claims.

Rescission procedural rules: To determine whether to rescind an exemption, issuer must conduct a retrospective review of a random sample of 5-20 payable claims from the most recent evaluation period; the issuer must provide at least 30 days for the provider to submit requested medical records; medical records requests for retrospective review should be limited to no more than 20 claims and may be made during the evaluation period or within 90 days after its end; if provider fails to provide necessary records, issuer may determine the claim would not have met screening criteria.

inv-04: Preauthorization exemption coverage criteria (excerpt)

Criteria for granting, denying, or rescinding preauthorization exemptions and related notice obligations.

Approval threshold: A physician or provider must have at least 90% approvals (i.e., issuer would have fully approved >=90% of claims) on eligible preauthorization requests or in a retrospective random sample of payable claims for the particular health care service to qualify for or retain an exemption; rescission occurs if fewer than 90% would have been approved.

Random sample size: Retrospective reviews for continued eligibility or rescission must be performed on a random sample of between 5 and 20 payable claims for the particular health care service.

Evidence submission timing: Issuer must provide at least 30 days for the provider to submit requested medical records for a retrospective review; records may be requested during the evaluation period or within 90 days following the end of the evaluation period; if rescission is appealed to an IRO because records were not submitted, the provider must include applicable records with the IRO request.

Claim coding requirement: When care is ordered by a provider with an exemption but rendered by a provider without an exemption, the ordering provider's name and NPI must be included on the claim in CMS Form 1500 fields 17/17B, UB-04 fields 76-79, or corresponding electronic fields; absent this, issuer may treat claim as subject to preauthorization.

inv-05: Administrative criteria for preauthorization exemptions

Procedural criteria for exemptions, notices, record requests, sample reviews, and independent review requests

Identification and reliance rules: Exemptions are tied to the NPI under which preauthorization requests were made; providers without an exemption may not rely on another provider's exemption except supervised providers ordering under the supervising physician's NPI.

Notice timing and content: Grant notices must explain the effect of the exemption and provide claim coding guidance; grant or denial notices after completing an evaluation must be issued within five days (with specific initial deadlines for the 2022 evaluation); rescission notices must be provided during the statutorily required months and include identification of the service, issue and effective dates, sample identification and determinations, principal reasons, clinical basis, sources of screening criteria, reviewer specialty, and appeal instructions including an IRO option at no cost.

Provider contact and appeal methods: Issuers must permit providers to designate email or mailing addresses for communications and allow submission of appeals by mail or electronic means; issuers must include instructions for updating contact preferences on communications and the issuer website.

Medical records requests and limits: For retrospective reviews, issuers may request medical records or other documents consistent with §19.1707, must provide at least 30 days to produce records, and should limit medical record requests to no more than 20 claims per particular health care service; records may be requested during the evaluation period or within 90 days after its end.

Claim Coding and Identification Requirements

Identifiers and claim coding guidancemixed

NPI	National Provider Identifier used to identify physician or provider making preauthorization requests for evaluation

Service-level countingmixed

If a preauthorization request includes multiple services (e.g., multi-drug regimens), outcomes for each service are counted separately in evaluations.

Claim identification requirementsmixed

NPI on claim

Claims must include ordering physician's or provider's NPI to identify exemptions when ordering provider is not the billing provider.

Claims coding requirements for exemptionsmixed

NPI	Use provider National Provider Identifier to identify provider making preauthorization requests
CMS1500 fields 17/17B; UB-04 76-79; ASC X12N 837 ordering/attending fields	Fields required to capture ordering physician/provider name and NPI when relying on another's exemption

Claims coding requirements for exemptions - notice/supportmixed

Rescission notice contents

Rescission notices must state total number of eligible claims, number included in random sample, and indicate if principal reason is failure to submit specified medical records; issuers must allow appeals by mail or electronic means.

Claim fields for documenting ordering providermixed

Form CMS-1500 fields 17 and 17B or UB-04 equivalent / ASC X12N 837 ordering NPI fields

Ordering physician name and NPI must be included on the claim when care ordered by an exempt provider is rendered by a non-exempt provider; if not included, issuer may treat claim as subject to preauthorization.

Minimum eligible requests

Minimum eligible preauthorization requests for evaluation5 eligible preauthorization requests must be available during the evaluation period to perform an initial exemption evaluation.

Source evaluation periodRequests must be submitted and finalized during the six-month evaluation period.

Counting multiple servicesIf a request includes more than one particular health care service, outcomes for each service are counted separately.

Exemption duration

Minimum exemption duration before rescissionAn exemption must be in place for at least 6 months before it can be rescinded.

Issuer and Provider Obligations, Notices, and Appeals

Prior Authorization

Issuer obligations for preauthorization exemptions

Issuers must review eligible preauthorization requests and grant exemptions to the physician or provider NPI that submitted the qualifying requests. For initial eligibility, an issuer must evaluate no fewer than five eligible preauthorization requests (the minimum threshold) for a particular health care service during the applicable evaluation period. When an exemption is granted, the issuer must provide a written notice to the physician or provider that includes a plain-language explanation of the effect of the exemption, the date the notice is issued, any claim coding guidance needed to document the exemption, and that the exemption will remain in place for at least six months before it may be rescinded. If an issuer receives a preauthorization request for a service for which an exemption has been granted, the issuer must provide notice consistent with Insurance Code §4201.659(e).

Exemptions are awarded to the physician or provider NPI that submitted the preauthorization request and are tied to the particular health care service listed by the issuer.
Initial evaluations for an exemption are based on preauthorization requests (not claims). Continued eligibility or rescission evaluations are based on payable claims submitted by or in connection with the exempt physician or provider.
Issuers must ensure systems and coding guidance allow inclusion of ordering/referring physician or provider name and NPI on claims so exemptions can be operationalized.

Key Definitions

Definition: Eligible preauthorization request

Eligible preauthorization request (definition)A preauthorization request submitted by the physician or provider and finalized by the health plan during the evaluation period, not pending appeal, with outcome of approval or adverse determination; modified and approved requests count for the approved service.

Count per serviceIf a preauthorization request includes more than one particular health care service, the outcome for each service must be counted separately.

Use in evaluationsEligible requests are the unit reviewed for initial exemption determinations under §19.1730(4)(A).

Definition: Evaluation

Evaluation (definition)A retrospective review used in two contexts: (A) for physicians/providers without an exemption, review of eligible preauthorization requests to decide grant/deny; (B) for those with an exemption, retrospective review of a random sample of payable claims to determine continuation or rescission.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyPreauthorization Exemptions (HB 3459 implementation)

Policy CodePolicy N/A

Change TypeMaterial revisions and clarifications to definitions, thresholds, notices, and appeals

Effective DateN/A

Next Review DateN/A

Key ActionEnsure claims include the ordering provider name and NPI in the specified claim fields so preauthorization exemptions can be applied.

SourceLink

On This Page

Service-level counting: If a preauthorization request includes multiple particular health care services (e.g., multi-drug regimens), outcomes for each service are counted separately for evaluation purposes.

Timing constraint: Rescissions may only be finalized in the months specified by Insurance Code §4201.655 (statutorily required months).

Notice requirements: Grant or denial notices must be provided within five days of completing an evaluation (initial notices for Jan 1–June 30, 2022 evaluation provided by Oct 1, 2022); rescission notices must include detailed sample information, principal reasons, clinical basis, sources of screening criteria, specialty of the reviewer, and appeal and IRO instructions; issuers must allow appeal forms to be returned by mail or electronic means and must allow providers to designate preferred contact method.

Independent review process: A provider may request independent review of a rescission before the rescission becomes effective by submitting the issuer's form; if rescission determinations were based on failure to provide records, the provider must include applicable records with the IRO request; if at least five additional eligible claims exist that were not included in the original sample, provider may request review of another random sample and the issuer must supply a detailed listing of those eligible claims to the IRO.

Independent review procedures: A provider may request IRO review of a rescission before it becomes effective by submitting the issuer's form; if rescission was based on failure to provide records, provider must include applicable records; if at least five additional eligible claims exist, provider may request IRO review of another random sample and issuer must supply a detailed listing of eligible claims not included in the original sample when submitting the request to TDI; the IRO must communicate its determination within five days.

Retention requirement to maintain exemption: To retain an exemption, a physician or provider must continue to maintain medical records adequate to demonstrate that health care services meet medical guidelines; absence of adequate records during evaluation or appeal may result in rescission.

Rescission timing constraintRescissions may be finalized only during the months specified by statute (January or June).

Effective date after noticeA rescission is not effective until at least 30 days after the issuer notifies the physician or provider.

Minimum eligible requests (restate)

Minimum eligible preauthorization requests5 eligible preauthorization requests are required to qualify for an initial preauthorization exemption.

Eligible request definitionAn eligible request is submitted by the physician or provider and finalized by the health plan during the evaluation period, not pending appeal, with an outcome of approval or adverse determination.

Modified approvalsA preauthorization request modified with acceptance of the provider and approved by the plan counts as an eligible request for the approved service.

Random sample size

Random sample size for rescission evaluationRandom samples for rescission evaluations must include between 5 and 20 claims.

Selection requirementClaims must be selected without method or conscious decision (i.e., randomly).

If ≤20 claims submittedIf only 5–20 claims were submitted in the period, all submitted claims may constitute the sample.

Minimum requests (detailed)

Minimum preauthorization requests for evaluationAt least 5 eligible preauthorization requests must be available to perform an evaluation for a particular service.

RationaleTDI reduced the proposed threshold from 20 to 5 to avoid limiting exemptions unnecessarily.

Evaluation basisMinimum threshold is based on preauthorization requests submitted and finalized during the six‑month evaluation period.

Rescission sample range

Rescission random sample size rangeRandom sample must include a minimum of 5 and a maximum of 20 payable claims for the particular health care service.

Medical records limitMedical records requested in connection with a retrospective random sample should be limited to no more than 20 claims.

Statutory alignmentRange aligns with Insurance Code §4201.655 which permits samples of not fewer than 5 and no more than 20 claims.

Minimums for evaluation

Minimum eligible preauthorization requests for evaluation5 eligible preauthorization requests are required to trigger an evaluation for a specific service.

Eligible request criteriaRequests must be submitted and finalized during the evaluation period and not pending appeal.

Counting multiple servicesIf a request includes multiple services, count outcomes separately per service.

Rescission random sample limits

Rescission random sample size range (min/max)Minimum: 5 claims; Maximum: 20 claims for the random sample used in retrospective review.

Random selection requirementClaims must be selected without method or conscious decision (i.e., randomly).

Limit on records requestedMedical records requests related to the sample should be limited to those claims (≤20).

Compliance threshold

Medical guideline compliance thresholdA physician or provider must meet the issuer's medical necessity/guideline criteria in at least 90% of cases to qualify for or retain an exemption.

Application to rescissionA rescission occurs if a retrospective sample indicates the issuer would have fully approved fewer than 90% of claims for the service.

Statutory basisThe 90% threshold is consistent with the statutory criteria referenced in the adopted rules.

Rescission notice timing

Rescission notice lead timeIssuers must provide notice at least 30 days before the rescission effective date (rescission not effective until 30 days after notice).

Rescission notice contentsNotice must include service identification, issue date, effective date, plain‑language appeal instructions, and sample information.

Timing monthsNotice of rescission must be provided during the months specified by statute (January or June applies to timing of notice).

Approval threshold

Exemption approval threshold>=90% approvals on eligible preauthorization requests (or payable claims in a retrospective sample) are required to grant or retain a preauthorization exemption.

Evaluation measurementFor initial grants, reviewers evaluate outcomes of eligible preauthorization requests; for rescission, reviewers evaluate a random sample of payable claims.

Rescission triggerAn adverse rescission determination is made when fewer than 90% of sampled claims would have met the issuer's medical necessity criteria.

Random sample requirements

Random sample sizeRetrospective reviews must use a random sample of a minimum of 5 and a maximum of 20 claims.

Random selection standardClaims must be selected without method or conscious decision to ensure randomness.

Record retentionIssuers should maintain records demonstrating random sampling, as commenters requested (statute allows issuer discretion).

Documentation Required

Appeal and independent review process

Providers must be given clear appeal rights and access to independent review when an exemption is denied or rescinded. For denials of exemption, issuers must send a denial notice describing reasons for the denial, how to appeal through the issuer's complaints and appeals process, and how to file a complaint with TDI. When rescinding an exemption, issuers must provide a rescission notice that includes the date issued, the total number of payable claims eligible for evaluation, the number of claims in the random sample, who made the determination, the principal reasons (including if based on failure to provide medical records), instructions on how to appeal, and instructions to include applicable medical records with any request for independent review when a determination was based on missing records. Providers must be allowed to return appeal forms by mail or electronic means, and issuers must offer providers the option to receive communications and submit appeals via mail or electronically and to indicate preferred contact information.

Denial notices must list reasons and explain appeal rights (issuer complaint process and TDI complaint filing).
Rescission notices must state the date issued, total eligible payable claims, number in random sample, and if the principal reason involves failure to submit specified medical records.
Appeal forms may be returned by paper or electronic means; requesting independent review requires the request to be postmarked or sent electronically before the rescission becomes effective.

Billing Rule

Claim identification and exemption qualification

To ensure exemptions are applied to claims, providers must include the ordering physician or provider's name and NPI on the claim: on CMS Form 1500 fields 17 and 17B, on UB-04 fields 76–79 (or another appropriate UB-04 field), or in the corresponding fields for electronic ASC X12N 837 claims. If this identifying information is not included, the issuer may treat the claim as subject to the otherwise applicable preauthorization requirement. Issuers may provide coding guidance to ensure the information is captured correctly.

CMS 1500: include ordering physician/provider name and NPI in fields 17/17B.
UB-04: include ordering physician/provider name and NPI in fields 76–79 or other appropriate field.
ASC X12N 837: include ordering physician/provider NPI in the corresponding electronic data element.

Prior Authorization

Exemption awarding and claim identification

Exemptions apply only to the particular health care service for which they were awarded and apply only to care ordered, referred, or provided by the physician or provider NPI that earned the exemption. The exemption is awarded to the physician or provider who submitted the preauthorization request used for the initial evaluation. Facilities may qualify for exemptions if they submit preauthorization requests under their own NPI, but exemptions are not transferable to other physicians or providers who did not earn them. Supervised providers (e.g., nurses, physician assistants) may rely on the supervising physician's exemption when they appropriately order care and request preauthorization under the supervising physician's NPI.

An exemption is specific to the health care service and to the NPI that qualified for it — other clinicians must continue to seek preauthorization under their own NPI.
If a rendering provider bills for care ordered by an exempt provider, the billing provider must include the ordering provider's NPI on the claim so the exemption can be applied.
Issuers may consider the exempt physician or provider to have failed to substantially perform the service if another provider without an exemption improperly relies on that exemption, which may result in reduced or denied payment under Insurance Code §4201.659.

Documentation Required

Independent review and evidence submission

When a rescission or other determination is based on a provider's failure to provide medical records, providers must include the applicable medical records with their request for independent review. A physician or provider has at least 30 days to provide medical records for an issuer's evaluation; records may be requested only during an evaluation period or within 90 days following the end of an evaluation period, and retrospective reviews are limited to a random sample of no more than 20 claims. If a provider timely requests independent review of a rescission, the issuer must submit the request to TDI only if the issuer seeks to proceed with the proposed rescission; the provider's request must document the date sent and be postmarked or sent electronically before the rescission becomes effective. Providers may also request that the IRO review another random sample if the rescission notice shows at least five additional eligible claims that were not included in the original sample; in that case the issuer must provide a detailed listing of payable claims not included in the original sample when submitting the independent review request to TDI.

Providers have at least 30 days to submit requested records; issuers may limit records requests in retrospective reviews to no more than 20 claims.
If the rescission determination cited missing records, the rescission notice must instruct the provider to include those records with any independent review request.
If requesting independent review of a rescission based on a claim sample, the provider must include applicable records with the appeal and document the date the appeal form was sent (electronically or by mail) before the rescission effective date.

PurposeEvaluations determine whether to grant, deny, continue, or rescind a preauthorization exemption based on approval percentages relative to medical necessity criteria.

Evaluation periodEvaluations assess activity during the six‑month evaluation period preceding the evaluation.

Definition: Physician (peer-to-peer)

Physician for peer‑to‑peerA physician used for peer‑to‑peer discussions or rescission determinations must be licensed to practice medicine in Texas and have the same or a similar specialty as the requesting physician; Texas administrative medicine licenses satisfy this requirement.

Statutory basisRequirement implements Insurance Code §4201.206 and related peer‑to‑peer provisions.

ApplicabilityUsed for peer‑to‑peer discussions before adverse determinations and for rescission determinations per statute.

Eligible preauthorization request (alt)

Eligible preauthorization request (alt wording)A preauthorization request submitted by the physician or provider and finalized by the health plan during the evaluation period that is not pending appeal and has an outcome of approval or adverse determination.

Modified approvals countA request modified with provider acceptance and approved by the plan counts as eligible for the approved service.

Use in initial evaluationsThese eligible requests are reviewed under §19.1730(4)(A) for initial grant/deny decisions.

Definition: Random sample

Random sample (definition)A collection of at least five but no more than 20 claims for a particular health care service, selected without method or conscious decision for retrospective evaluation.

PurposeUsed to evaluate a physician's or provider's continued eligibility for a preauthorization exemption.

Selection noteIf only 5–20 claims exist in the period, all may constitute the sample; otherwise selection should be random (equal chance for each claim).

Definition: Treating physician or provider

Treating physician or provider (definition)The physician or other provider primarily responsible for a patient's health and medical care; includes rendering, referring, or ordering providers.

Ordering providers includedDefinition explicitly expands to include ordering providers so exemptions can apply when ordering and rendering providers differ.

Relevance to claimsClaims must include ordering provider information to apply an exemption when the rendering provider is different.

Particular health care service (short)

Particular health care service (short)A particular health care service may include pharmaceutical services and prescription drugs, labs, imaging, equipment, and supplies as interpreted by TDI under statutory definitions.

Use in rulesDetermines the unit of analysis for exemptions, evaluations, and rescissions.

Stakeholder monitoringTDI will monitor implementation and may request information from stakeholders as exemptions are implemented.

Eligible preauthorization request (short alt)

Eligible preauthorization request (short)Eligible preauthorization request: a preauthorization request submitted and finalized during the evaluation period, not pending appeal, with outcome either approved or adverse.

Evaluation linkageThese requests are used in initial evaluations to determine whether to grant or deny an exemption under §19.1730(4)(A).

Minimum count for noticeAn issuer need only provide grant/deny notice if it completed an evaluation of at least five eligible requests.

Adverse determination (preauthorization exemption)

Adverse determination regarding a preauthorization exemptionA decision that one or more claims retrospectively reviewed did not meet the issuer's screening criteria and leads to rescission of a preauthorization exemption.

Not same as §19.1703 adverse determinationThis adverse determination is distinct from adverse determinations defined under §19.1703.

Basis for rescissionTypically based on retrospective review of a random sample and consistent with Insurance Code §4201.655 requirements.

Adverse determination (alt)

Adverse determination regarding a preauthorization exemption (alt)An adverse determination concluding issuer would have fully approved fewer than 90% of claims for the particular health care service after a retrospective sample review, potentially prompting rescission.

Decision maker requirementFor physician exemptions, rescission determinations must comply with Insurance Code §4201.655(b), including decision by a Texas‑licensed physician of same/similar specialty.

Evaluation referenceDefinition references the applicable evaluation definition for rescission determinations (§19.1730(4)(B)).

Eligible preauthorization request (detailed)

Eligible preauthorization request (detailed)A request submitted and finalized during the evaluation period, not pending appeal, with outcome of approval or adverse determination; modifications accepted by the provider and approved by the plan count for the approved service.

Use for evaluationsCounted in evaluations under §19.1730(4)(A) for grant/deny decisions.

Service‑level countingIf a request covers multiple services, each service outcome is counted separately.

Evaluation (detailed)

Evaluation (detailed)(A) Review of eligible preauthorization requests to decide whether to grant or deny an exemption; (B) Retrospective review of a random sample of payable claims to evaluate whether to continue or rescind an exemption.

Standards appliedRetrospective reviews assess whether claims would have met the issuer's applicable medical necessity criteria at the time of service.

Statutory consistencyRetrospective reviews are conducted consistent with Insurance Code §4201.655 for rescission determinations.

Random sample (definition)

Random sample (definition)A random sample is at least five and no more than 20 claims selected without method or conscious decision for evaluation of continued exemption eligibility.

Selection expectationsThe sample must give each claim an equal chance of selection; issuer should maintain sampling records if practical.

When fewer claims existIf only 5–20 claims exist, all may constitute the sample for the evaluation.

Treating physician or provider (expanded)

Treating physician or provider (expanded)A provider responsible for health and medical care for a patient; explicitly includes ordering, referring, and rendering providers.

Implication for exemptionsAllows exemptions to apply when the ordering/provider who obtained the exemption is not the billing/rendering provider.

Claims requirement tie‑inClaims must include ordering provider info so exemptions can be applied when ordering and rendering providers differ.

Adverse determination & rescission

Adverse determination regarding a preauthorization exemptionAn adverse determination regarding a preauthorization exemption is a decision that leads to rescission and must include sample information and comply with statutory notice and appeal rights.

Appeal timingA provider may request independent review any time before the rescission becomes effective; the request must be postmarked or sent electronically before the effective date.

IRO involvementIf rescission is appealed, the issuer must submit the request for independent review to TDI and include records when the rescission was based on failure to provide records.