Within the "MH/SUD Parity Rule Division 2 Data Collection Reporting Form" template, in the worksheet titled "Claims and Utilization Review," for medical/surgical, MH/SUD, and for each of the classifications listed in §21.2425(c) of this title (relating to Claims and Utilization Review: Reporting Classifications), an issuer must provide the following aggregate claims and utilization review data for the reporting year:
  (1) the number of reported claims for services or benefits that have been provided:
    (A) in total;
    (B) by out-of-network providers that were covered as in-network benefits;
    (C) that were approved;
    (D) that were administratively denied; and
    (E) that were adversely determined;
  (2) the number of utilization reviews, including:
    (A) preauthorization requests for:
      (i) children ages 0 - 12;
      (ii) adolescents ages 13 - 17; and
      (iii) adults;
    (B) preauthorization requests approved for:
      (i) children ages 0 - 12;
      (ii) adolescents ages 13 - 17; and
      (iii) adults;
    (C) preauthorization requests that received a peer-to-peer or physician-to-physician review for:
      (i) children ages 0 - 12;
      (ii) adolescents ages 13 - 17; and
      (iii) adults;
    (D) preauthorization requests that were subject to a fail-first or step therapy requirement;
    (E) preauthorization requests that were adversely determined for:
      (i) children ages 0 - 12;
      (ii) adolescents ages 13 - 17; and
      (iii) adults;
    (F) concurrent reviews for:
      (i) children ages 0 - 12;
      (ii) adolescents ages 13 - 17; and
      (iii) adults;
    (G) concurrent reviews approved for:
      (i) children ages 0 - 12;
      (ii) adolescents ages 13 - 17; and
      (iii) adults;
    (H) concurrent reviews that received a peer-to-peer or physician-to-physician review for:
      (i) children ages 0 - 12;
      (ii) adolescents ages 13 - 17; and
      (iii) adults;
    (I) concurrent reviews that were adversely determined for:
      (i) children ages 0 - 12;
      (ii) adolescents ages 13 - 17; and
      (iii) adults;
    (J) retrospective reviews for:
      (i) children ages 0 - 12;
      (ii) adolescents ages 13 - 17; and
      (iii) adults;
    (K) retrospective reviews that were approved for:
      (i) children ages 0 - 12;
      (ii) adolescents ages 13 - 17; and
      (iii) adults;
    (L) retrospective reviews that received a peer-to-peer or physician-to-physician review for:
      (i) children ages 0 - 12;
      (ii) adolescents ages 13 - 17; and
      (iii) adults; and
    (M) retrospective reviews that were adversely determined for:
      (i) children ages 0 - 12;
      (ii) adolescents ages 13 - 17; and
      (iii) adults;
  (3) the number of adverse determinations that were internally appealed that:
    (A) then received a peer-to-peer or physician-to-physician review on internal appeal;
    (B) were again adversely determined on internal appeal; and
    (C) were reversed on internal appeal; and
  (4) the number of adverse determinations independently reviewed that were:
    (A) upheld on independent review; and
    (B) reversed on independent review.

Source Note: The provisions of this §21.2426 adopted to be effective September 7, 2021, 46 TexReg 5571