(a) After receipt of a written certification of creditable coverage as provided under §21.1103 of this title (relating to Timing of Issuance of a Written Certificate of Creditable Coverage to an Individual) or other means as provided under §21.1107 of this title (relating to Creditable Coverage Established Through Means Other Than Written Certificate), an issuer of a health benefit plan shall as soon as reasonably possible, not to exceed 30 days after receipt of the information regarding creditable coverage, make a determination regarding the individual's period of creditable coverage and notify the individual to whom a preexisting condition exclusion period is to apply of its determination in accordance with subsection (b) of this section.
(b) An issuer of a health benefit plan seeking to impose a preexisting condition exclusion shall disclose to the individual, in writing, its determination of any preexisting condition exclusion period that applies to the individual as soon as reasonably possible, not to exceed 30 days after receipt of the information regarding creditable coverage. The issuer of a health benefit plan shall disclose the basis for such determination, including the source and substance of any information on which the issuer relied. The issuer of a health benefit plan shall establish a grievance procedure in accordance with applicable law and shall notify the individual in writing of such grievance procedure. The issuer of a health benefit plan shall provide an individual with a reasonable opportunity to submit additional evidence of creditable coverage.
(c) An issuer of a health benefit plan may modify an initial determination of creditable coverage if the issuer determines the individual did not have the claimed creditable coverage, provided that:
  (1) a notice of the reconsideration is provided to the individual; and
  (2) until the final determination is made, the issuer of the health benefit plan, for purposes of approving access to medical services, acts in a manner consistent with the initial determination.

Source Note: The provisions of this §21.1108 adopted to be effective December 22, 1997, 22 TexReg 12513.