Texas Prior Authorization Law

Overview

Texas HB 3459 (2023) reformed prior authorization requirements. Insurers must decide standard requests within 3 business days and urgent requests within 24 hours. The law introduces gold-carding: providers with 90% or higher approval rates are exempt from future prior auth for the same service. Denials require peer-to-peer review with a physician.

Key Requirements

1. Insurers must acknowledge prior authorization requests within 1 business day.
2. Standard requests must be decided within 3 business days of receipt of a complete submission.
3. Urgent requests must be decided within 24 hours of receipt.
4. Providers with 90%+ approval rate qualify for gold-carding (exemption from future prior auth requests).
5. Denials must include peer-to-peer discussion between treating physician and insurer physician.

Penalties and Enforcement

Texas Department of Insurance enforces HB 3459 with fines for timeline violations. Failure to provide peer-to-peer review for denials can result in automatic approval. Systematic violations trigger regulatory action and potential license restrictions. Failure to honor gold-carding status violates the statute.

Appeals and Exceptions

Denied prior authorization requests can be appealed to the insurer's medical director within 30 days. Peer-to-peer review is mandatory for all denials. If the insurer fails to provide peer-to-peer review, the prior authorization request is deemed approved.

Interaction with Federal Law

Texas HB 3459 exceeds federal prior authorization standards. Gold-carding and peer-to-peer requirements are state-specific innovations. Federal ERISA rules do not preempt Texas protections for fully-insured plans.

Common Questions