A health maintenance organization or insurer may not require preauthorization for a service when the physician or provider meets the stated approval-rate and service-use criteria.
Sec. 4201.653. EXEMPTION FROM PREAUTHORIZATION REQUIREMENTS FOR PHYSICIANS AND PROVIDERS PROVIDING CERTAIN HEALTH CARE SERVICES. (a) A health maintenance organization or an insurer that uses a preauthorization process for health care services may not require a physician or provider to obtain preauthorization for a particular health care service if, in the most recent one-year evaluation period, as described by Subsection (b): (1) the health maintenance organization or insurer, including any affiliate, has approved or would have approved not less than 90 percent of the preauthorization requests submitted by the physician or provider for the particular health care service; and (2) the physician or provider has provided the particular health care service at least five times during the evaluation period. (a-1) In conducting an evaluation for an exemption under this section, a health maintenance organization or insurer must include all preauthorization requests submitted by a physician or provider to the health maintenance organization or insurer, or its affiliate, considering all health insurance policies and health benefit plans issued or administered by the health maintenance organization or insurer, or its affiliate, regardless of whether the preauthorization request was made in connection with a health insurance policy or health benefit plan that is subject to this subchapter. (b) Except as provided by Subsection (c), a health maintenance organization or insurer shall evaluate whether a physician or provider qualifies for an exemption from preauthorization requirements under Subsection (a) once every year. (c) A health maintenance organization or insurer may continue an exemption under Subsection (a) without evaluating whether the physician or provider qualifies for the exemption under Subsection (a) for a particular evaluation period. (d) A physician or provider is not required to request an exemption under Subsection (a) to qualify for the exemption. Added by Acts 2021, 87th Leg., R.S., Ch. 1018 (H.B. 3459), Sec. 5, eff. September 1, 2021. Amended by: Acts 2025, 89th Leg., R.S., Ch. 640 (H.B. 3812), Sec. 3, eff. September 1, 2025.