TX STATE SPECIFIC REQUIREMENTS

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Benefits payable for Hospital Inpatient Confinement Charges and confinement charges for services provided in an inpatient confinement facility will be reduced by 30% unless:

For Hospital Inpatient Confinement Charges and charges for services provided in an inpatient confinement facility, a Precertification is requested from the Company by the Insured Person     or a designated patient representative as soon as a Hospital Inpatient Confinement or confinement in an inpatient confinement facility is scheduled, but no later than the day of a Hospital Inpatient Confinement or confinement in an inpatient confinement facility, for other than Emergency Services.

If a Precertification is not requested in a timely manner as specified above, the 30% reduction in benefits payable will be applied to all non-emergency Hospital Inpatient Confinement Charges and charges in an inpatient confinement facility.

For the purpose of these requirements, "Precertification" means notification to the Company by the Insured Person or his or her designated representative prior to a non-emergency Hospital Inpatient Confinement or confinement in an inpatient confinement facility.

Benefits will be payable only for that part of the Hospital Inpatient Confinement Charges or inpatient confinement facility charges that the Company determines to be a Covered Charge.

An inpatient confinement facility includes:

• Hospital;
• Skilled Nursing Facility;
• Rehabilitation hospital;
• Hospice;
• Long term acute care facility;
• Psychiatric Hospital or psychiatric unit of a general hospital for Mental Health and Behavioral Treatment Services;
• Inpatient Alcohol or Drug Abuse Treatment Facility or drug or alcohol unit of a general hospital or any other facility required by state law to be recognized as a treatment facility under the Group Policy for Alcohol and Drug Abuse Treatment Services;
• Partial Hospitalization or Day Treatment Facility for Mental Health, Behavioral, Alcohol and Drug Abuse Treatment Services.

Certain exceptions apply to Hospital Inpatient Confinement for childbirth as described below.

For Emergency Services, the Insured Person or a designated patient representative must contact the Company within two business days of a Hospital Inpatient Confinement or of a confinement in an inpatient confinement facility.

The 30% reduction in Benefits Payable is a penalty for failure to comply with the Utilization Management Requirements listed.  The reduction:

• will not count toward satisfaction of the Out-of-Pocket Expense limits; and
• will not exceed $10,000 per individual each Calendar Year.
• Precertification Applicable to medical care received from PPO Providers or Non-Preferred Providers

A Precertification by the Company is required for all Hospital Inpatient Confinements or inpatient facility confinements.

Precertification requires a review by the Company of a Physician's report of the need for a Hospital Inpatient Confinement or confinement in an inpatient confinement facility, (unless it is for an automatically approved Hospital Inpatient Confinement for childbirth).

The report (verbal or Written) must include the:

• reason(s) for the Hospital Inpatient Confinement or confinement in an inpatient confinement facility; and
• significant symptoms, physical findings, and treatment plan; and
• procedures performed or to be performed during the Hospital Inpatient Confinement or confinement in an inpatient confinement facility; and
• estimated length of the Hospital Inpatient Confinement or confinement in an inpatient confinement facility.

If a Hospital Inpatient Confinement or confinement in an inpatient confinement facility will exceed the approved number of days, the Company will initiate a Continued Stay Review.  For the purpose of these requirements, Continued Stay Review means a review by the Company of a Physician's report of the need for continued Hospital Inpatient Confinement or confinement in an inpatient confinement facility.

The report (verbal or Written) must include the:

•   reason(s) for requesting continued Hospital Inpatient Confinement or confinement in an inpatient confinement facility; and
• significant symptoms, physical findings, and treatment plan; and
• procedures performed or to be performed during the Hospital Inpatient Confinement or confinement in an inpatient confinement facility; and
• estimated length of the continued Hospital Inpatient Confinement or confinement in an inpatient confinement facility.

Charges incurred for room, board and other usual services, including Physician Visits that are in excess of those approved by the Company for Inpatient Hospital Confinement or confinement in an inpatient confinement facility will not be considered Covered Charges.

The following exception applies to Hospital Inpatient Confinement for childbirth.

Covered Charge requirements are waived and a Precertification is not required for mother and baby, for:

• A 48-hour Hospital Inpatient Confinement following vaginal delivery; or
• A 96-hour Hospital Inpatient Confinement following cesarean section.

A request for review by the Company of the need for continued Hospital Inpatient Confinement for mother or baby beyond the automatically approved time period stated above must be made by the Insured Person or a designated patient representative before the end of that time period.

If the Insured Person or a designated patient representative fails to request a review as specified in this section, benefits will be reduced as described above.

Exception:  For all Hospital Inpatient Confinement Charges incurred beyond the 48-hour or 96-hour automatically approved Hospital Inpatient Confinement for childbirth, the penalty will be applied beginning the day after the automatically approved time period ends.  Except as waived above, no benefits will be payable for any Treatment or Service that is not a Covered Charge.

• Concurrent Review : Utilization Review conducted during an Insured Person's Hospital stay or course of treatment

• Continued Stay Review : A review by the Company of a Physician's report of the need for continued Hospital Inpatient Confinement or confinement in an inpatient confinement facility to determine if the continued stay is a Covered Charge.

• Health Professional : An individual who:
  • has undergone formal training in a health care field; holds an associate or higher degree in a health care field, or holds a state license or state certificate in a health care field; and
  • has professional experience in providing direct patient care.

• Initial Clinical Review(er) : Clinical review conducted by appropriate licensed or certified Health Professionals.  Initial Clinical Review staff may approve requests for admissions, procedures, and services that meet clinical review criteria, but must refer requests that do not meet clinical review criteria to a Peer Clinical Reviewer for certification or Adverse Benefit Determination.

• Notification of Utilization Review Services : Receipt of necessary information to initiate review of a request for Utilization Review services to include the Insured Person's name and the Member's name (if different from Insured Person's name), attending Physician's name, treatment facility's name, diagnosis, and date of service.

• Ordering Provider : The Physician or other provider who specifically prescribes the health care service being reviewed.

• Peer Clinical Review(er) : Clinical review conducted by a Physician or other Health Professional when a request for an admission, procedure, or service was not approved during the Initial Clinical Review.
• In the case of an appeal review, the Peer Clinical Reviewer is a Physician or other Health Professional who holds an unrestricted license and is in the same or similar specialty as typically manages the medical condition, procedures, or treatment under review.  Generally, as a peer in a similar specialty, the individual must be in the same profession, i.e., the same licensure category as the Ordering Provider.

• Precertification : A review by the Company of a Physician's report of the need for a Hospital Inpatient Confinement or a confinement in an inpatient confinement facility (unless it is for an automatically approved Hospital Inpatient Confinement for childbirth).

• Prospective Review : Utilization Review conducted prior to an Insured Person's stay in a Hospital or other health care facility or course of treatment, including any required preauthorization or Precertification.

• Retrospective Review : Utilization Review conducted after the Insured Person is discharged from a Hospital or other health care facility or has completed a course of treatment.

• Urgent Review : Utilization Review that must be completed sooner than a Prospective Review in order to prevent serious jeopardy to an Insured Person's life or health or the ability to regain maximum function, or in the opinion of a Physician with knowledge of the Insured Person's medical condition, would subject the Insured Person to severe pain that cannot be adequately managed without treatment.  Whether or not there is a need for an Urgent Review is based upon the Company's determination using the judgment of a prudent layperson who possesses an average knowledge of health and medicine.  An Insured Person's provider should not request an Urgent Review for a situation in which the provider or Insured Person has had adequate time to request standard Precertification.

• Utilization Management : The administration of Utilization Review procedures, such as Precertification of hospital admissions and inpatient confinements, monitoring services during a course of treatment, discharge planning, peer reviews, case management and appeals.

• Utilization Review : The evaluation of the clinical necessity, appropriateness, efficacy or efficiency of health care services, procedures, providers, or facilities according to a set of formal techniques and guidelines.

• Prospective Review : For an initial Prospective Review, a decision and notification of the decision will be made within 15 calendar days of the date the Company receives Notification of Utilization Review Services.  If a decision cannot be made due to insufficient information, the Company will either issue an Adverse Benefit Determination or send an explanation of the information needed to complete the review prior to expiration of the 15 calendar days.  If the Company does not issue an Adverse Benefit Determination and requests additional information to complete the review, the Insured Person, the attending Physician or other Ordering Provider, or the facility rendering the service is permitted up to 45 calendar days to provide the necessary information.  The Company will render a decision within 15 calendar days of either receiving the necessary information or the expiration of 45 calendar days, if no additional information is received.  For certifications, the Company will provide notification to the attending Physician or other Ordering Provider, the facility rendering service and the Insured Person.  Upon request, the Company will provide Written notification of the certification.  Adverse Benefit Determinations will be made in Writing to the attending Physician or other Ordering Provider, the facility rendering service and the Insured Person.

• Urgent Prospective Review ; For Urgent Review of a Prospective Review, a decision and notification of the decision will be made within 72 hours of the date the Company receives Notification of Utilization Review Services.  If a decision cannot be made due to insufficient information, the Company will either issue an Adverse Benefit Determination or send an explanation of the information needed to complete the review within 24 hours of receipt of Notification of Utilization Review Services.  If the Company does not issue an Adverse Benefit Determination and requests additional information to complete the review, the Insured Person, the attending Physician or other Ordering Provider, or the facility rendering the service is permitted up to 48 hours to provide the necessary information.  The Company will render a decision within 48 hours of either receiving the necessary information or if no additional information is received, the expiration of the 48 hours to provide the specified additional information.  For certifications, the Company will provide notification to the attending Physician or other Ordering Provider, the facility rendering service and the Insured Person.  Upon request, the Company will provide Written notification of the certification. Adverse Benefit Determinations will be made in Writing to the attending Physician or other Ordering Provider, the facility rendering service and the Insured Person.

• Concurrent Review : For a Concurrent Review that does not involve an Urgent Review, a request to extend a course of treatment beyond the period of time or number of treatments previously approved by the Company will be decided within the timeframes and according to the requirements for Prospective Review.

• Urgent Concurrent Review : For an Urgent Review of a Concurrent Review, a request to extend a course of treatment beyond the period of time or number of treatments previously approved by the Company will be decided and notification of the decision will be made within 24 hours of receipt of the Notification of Utilization Review Services if the request is made at least 24 hours prior to the expiration of the previously approved period or number of treatments.  If a request is made less than 24 hours prior to the expiration of the previously approved period or number of treatments, a decision and notification of the decision will be made within 72 hours of receipt of the Notification of Utilization Review Services.

• Retrospective Review : For a Retrospective Review, a decision and notification of the decision will be made within 30 calendar days after the Company receives Notification of Utilization Review Services.  If a decision cannot be made due to insufficient information, the Company will either issue an Adverse Benefit Determination or send an explanation of the information needed to complete the review prior to the expiration of the 30 calendar days.  If the Company does not issue an Adverse Benefit Determination and requests additional information to complete the review, the Insured Person, the attending Physician or other Ordering Provider, or the facility rendering the service is permitted up to 45 calendar days to provide the necessary information.  The Company will render a decision within 15 calendar days of either receiving the necessary information or the expiration of 45 calendar days, if no additional information is received.  For certifications, the Company will provide notification to the attending Physician or other Ordering Provider, the facility rendering service and the Insured Person.  Upon request, the Company will provide Written notification of the certification.  Adverse Benefit Determinations will be made in Writing to the attending Physician or other Ordering Provider, the facility rendering service and the Insured Person.

• 2019 Texas Utilization Management In-Patient Prior-Authorization Data for Nippon Life Benefits