Texas Insurance Code - INS § 4201.655. Denial or Rescission of Preauthorization Exemption

(1) during January of a year beginning on or after the first anniversary of the last day of the most recent evaluation period for the exemption;

(2) if the health maintenance organization or insurer makes a determination, on the basis of a retrospective review of a random sample of not fewer than five and no more than 20 claims submitted by the physician or provider during the most recent evaluation period described by Section 4201.653(b), that less than 90 percent of the claims for the particular health care service met the medical necessity criteria that would have been used by the health maintenance organization or insurer when conducting preauthorization review for the particular health care service during the relevant evaluation period;  and

(3) if the health maintenance organization or insurer complies with other applicable requirements specified in this section, including:

(1) the physician or provider does not have the exemption at the time of the relevant evaluation period;  and

(2) the health maintenance organization or insurer provides the physician or provider with actual statistics and data for the relevant preauthorization request evaluation period and detailed information sufficient to demonstrate that the physician or provider does not meet the criteria for an exemption from preauthorization requirements for the particular health care service under Section 4201.653.