SECTION 21.2426. Claims and Utilization Review: Aggregate Data Fields

Within the "MH/SUD Parity Rule Division 2 Data Collection Reporting Form" template, in the worksheet titled "Claims and Utilization Review," for medical/surgical, MH/SUD, and for each of the classifications listed in §21.2425(c) of this title (relating to Claims and Utilization Review: Reporting Classifications), an issuer must provide the following aggregate claims and utilization review data for the reporting year:

(1) the number of reported claims for services or benefits that have been provided:

(A) in total;

(B) by out-of-network providers that were covered as in-network benefits;

(C) that were approved;

(D) that were administratively denied; and

(E) that were adversely determined;

(2) the number of utilization reviews, including:

(A) preauthorization requests for:

(i) children ages 0 - 12;

(ii) adolescents ages 13 - 17; and

(iii) adults;

(B) preauthorization requests approved for:

(i) children ages 0 - 12;

(ii) adolescents ages 13 - 17; and

(iii) adults;

(C) preauthorization requests that received a peer-to-peer or physician-to-physician review for:

(i) children ages 0 - 12;

(ii) adolescents ages 13 - 17; and

(iii) adults;

(D) preauthorization requests that were subject to a fail-first or step therapy requirement;

(E) preauthorization requests that were adversely determined for:

(i) children ages 0 - 12;

(ii) adolescents ages 13 - 17; and

(iii) adults;

(F) concurrent reviews for:

(i) children ages 0 - 12;

(ii) adolescents ages 13 - 17; and

(iii) adults;

(G) concurrent reviews approved for:

(i) children ages 0 - 12;

(ii) adolescents ages 13 - 17; and

(iii) adults;

(H) concurrent reviews that received a peer-to-peer or physician-to-physician review for:

(i) children ages 0 - 12;

(ii) adolescents ages 13 - 17; and

(iii) adults;

(I) concurrent reviews that were adversely determined for:

(i) children ages 0 - 12;

(ii) adolescents ages 13 - 17; and

(iii) adults;

(J) retrospective reviews for:

(i) children ages 0 - 12;

(ii) adolescents ages 13 - 17; and

(iii) adults;

(K) retrospective reviews that were approved for:

(i) children ages 0 - 12;

(ii) adolescents ages 13 - 17; and

(iii) adults;

(L) retrospective reviews that received a peer-to-peer or physician-to-physician review for:

(i) children ages 0 - 12;

(ii) adolescents ages 13 - 17; and

(iii) adults; and

(M) retrospective reviews that were adversely determined for:

(i) children ages 0 - 12;

(ii) adolescents ages 13 - 17; and

(iii) adults;

(3) the number of adverse determinations that were internally appealed that:

(A) then received a peer-to-peer or physician-to-physician review on internal appeal;

(B) were again adversely determined on internal appeal; and

(C) were reversed on internal appeal; and

(4) the number of adverse determinations independently reviewed that were:

(A) upheld on independent review; and

(B) reversed on independent review.

Source Note: The provisions of this §21.2426 adopted to be effective September 7, 2021, 46 TexReg 5571