1. (a) In this section, "preauthorization" has the meaning assigned by the Insurance Code §1352.004(a), and includes benefit determinations for proposed medical or health care services.

2. (b) Each issuer shall develop written preauthorization and utilization review policies and procedures for the purpose of identifying services to be covered for acquired brain injury to be utilized by any individual responsible for preauthorization of coverage or utilization review. Such policies and procedures shall include:

   1. (1) identification of all current Common Procedural Terminology (CPT) codes associated with services for acquired brain injury; and
   2. (2) a means to identify an enrollee initially diagnosed with an acquired brain injury.

3. (c) Each health benefit plan issuer shall 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 the Insurance Code Chapter 1352 and this subchapter, and to avoid confusion of medical/surgical benefits with mental/behavioral health benefits. At a minimum, training shall consist of:

   1. (1) identification of services likely to be requested in treating an enrollee with an acquired brain injury;
   2. (2) identification of specific therapies currently used in treating an enrollee with an acquired brain injury;
   3. (3) instruction relating to correctly evaluating requests for services to differentiate between covered medical/surgical benefits versus covered benefits for mental/behavioral health; and
   4. (4) instruction relating to the requirements of the Insurance Code Chapter 1352 and this subchapter.

4. (d) At a minimum, training shall be accomplished by attendance at an initial orientation, inservice, or continuing education program relating to acquired brain injuries and their treatments, provided that such training shall be consistent with the requirements of subsections (a) and (b) of this section.

   1. (1) Documentation and verification of training shall be maintained for each employee or staff member responsible for preauthorization of coverage, utilization review, or any individual performing these processes.
   2. (2) Upon request, any documentation and verification required by paragraph (1) of this subsection shall be provided to the issuer with whom the employee, staff member, or individual is employed or contracted.
   3. (3) Upon request, any documentation and verification required by paragraph (1) of this subsection shall be provided to the department for review.
5. (e) The requirements of this section shall also apply to any contracted entity of an issuer to the extent the contracted entity is responsible for preauthorization, or utilization review.

Source Note:The provisions of this §21.3104 adopted to be effective August 26, 2002, 27 TexReg 7814; amended to be effective February 23, 2009, 34 TexReg 1247.