Prior Authorization

HB 3459 & the Texas Gold Card

The 2021 Texas Legislature Solved the Challenge of Unnecessary Prior Authorizations

Unnecessary Prior Authorizations Should Not Stand Between Patients And Physicians

Data show that approximately one percent of prior authorization requests are ultimately denied by insurers. Unfortunately, prior authorization requests simply serve as an unnecessary barrier between patients and their physicians.

The 2021 Texas Legislature recognized this when all 31 members of the Texas Senate voted to pass the prior authorization gold card law.

The 2021 Texas “gold card” law serves as the model for prior authorization reform in other states and at the federal level.

Prior Authorization Reform

The Numbers

90%

Threshold for Prior Authorization Exemption Under the Texas Law

100%

All 31 Texas Senators Voted for the Gold Card Law

3

Three Key Laws Passed by the Texas Legislature in 2021 & 2019

Washington

Congressional Legislation

HR 7995

Congressional Gold Card Bill

HR 8487

Medicare Advantage Prior Auth

HR 3173

Second Medicare Advantage Bill


The 2021 Texas Law: HB 3459
The Provisions

Gold Card: 10.1.22

  • Physicians who are approved for a particular service at least 90 percent of the time during a six-month evaluation period will be exempt for that service under the new law.
  • The six-month evaluation period went into effect on January 1, 2022. The Texas Department of Insurance released the final rule.

Peer Reviews by Texas Physicians

  • Before an adverse determination is made, the law requires a peer to peer in which health plans must use physicians who are licensed in the state of Texas.
  • The reviewer must have the “same or similar speciality” as the physician who is subject to a review.

Click here to view the 2021 Texas Law.

Click here to view the Texas Department of Insurance’s August 15, 2022, final rule.

TOA members can check their e-mails for TOA’s summary.


2019 Texas Law: SB 1742
Prior Authorization Transparency & New Utilization Review Requirements

Prior Authorization Transparency

  • The law requires health plans to post a detailed description of the prior authorization process and procedures and a list of the supporting documentation that physicians are required to provide.

Website Notice for Each PA Requirement

  • Effective date.
  • List of supporting documentation required.
  • Applicable screening criteria (codes).
  • Statistics regarding PA approval and denial rates in the preceding calendar year. These include denials overturned on internal appeal and denials overturned by an IRO.

Click here to read the 2019 Texas Law.

Click here to read the TDI Commissioner’s Bulletin, which summarizes the UR and adverse determination law from 2019.

UR Agents & Adverse Determinations

  • Click here to read the TDI Commissioner’s Bulletin from 2019, which summarizes the state’s rules and laws related to utilization review and adverse determinations.

Of the Same or Similar Specialty

  • All utilization reviews for services ordered by a physician must be reviewed by a licensed physician.
  • Specialty physicians have the option of requesting that a denial or a denial of an appeal be reviewed by a physician of the same or similar specialty.    

Health Plan Prior Authorization Statistics: 2019 Law


2019 Texas Law: HB 3041
Prior Authorization Renewal Requests

60-Day Renewal of an Existing PA

  • A physician may request the renewal of an existing prior authorization for at least 60 days before it expires.

Click here to read the law.