TX HB3812

Utilization review agents must conduct reviews under direction of a Texas-licensed physician who does not hold an administrative medicine license

Physicians and providers qualify for preauthorization exemptions if the insurer approved at least 90% of their requests for a particular service during a one-year evaluation period (changed from six months) and provided that service at least five times

HMOs and insurers must include all preauthorization requests across all affiliated entities and health plans when evaluating exemption eligibility, not just requests from plans subject to this subchapter

Exemption rescissions may only occur in January of any year beginning on or after the first anniversary of the last evaluation period, and must be based on retrospective review of 5-20 claims showing less than 90% met medical necessity criteria

HMOs and insurers must submit annual public reports to the Texas Department of Insurance detailing exemptions granted, exemptions denied or rescinded, and outcomes of independent reviews

Takes effect September 1, 2025, with existing exemptions protected from rescission until one year after their most recent evaluation period