235.034 Authorizations Initiated by Third-Party Payers

235.034

235.034 Authorizations Initiated by Third-Party Payers, Benefit Managers, and Utilization Review Entities: The Texas Medical Association supports policy and legislation that (1) third-party payers, benefit managers, and utilization review entities may not implement prior authorization mechanisms unless these payers compensate physician practices for work required independent of any payment for patient care; specifically, medical practices must be compensated for the burden of added staff and resources required to navigate payer-initiated prior authorizations for medications, studies, or procedures; (2) third-party payers, benefit managers, and utilization review entities should disclose all prior authorization requirements and restrictions on their websites in both the subscriber section and the physician section with neither location requiring a log-in or password; (3) third-party payers, benefit managers and utilization review entities should confirm patient eligibility, payment determinations, medical policies and subscriber specific exclusions as part of the prior authorization process; and (4) third-party payers, benefit managers, and utilization review entities should make detailed statistics regarding prior authorization approval and denial rates available on their website (Res. 401-A-11) (CSE Rep. 3-A-18).

Last Updated On

August 14, 2018