Texas Statutes
Insurance Code
Title 14 - Utilization Review and Independent Review

Section 4201.051. Persons Providing Information About Scope of Coverage or Benefits - Sec. 4201.051. PERSONS PROVIDING INFORMATION ABOUT SCOPE OF COVERAGE OR...

Section 4201.052. Certain Contracts With Federal Government - Sec. 4201.052. CERTAIN CONTRACTS WITH FEDERAL GOVERNMENT. This chapter does...

Section 4201.053. Medicaid and Other State Health or Mental Health Programs - Sec. 4201.053. MEDICAID AND OTHER STATE HEALTH OR MENTAL HEALTH...

Section 4201.054. Workers' Compensation Benefits - Sec. 4201.054. WORKERS' COMPENSATION BENEFITS. (a) Except as provided by...

Section 4201.055. Health Care Service Provided Under Automobile Insurance Policy - Sec. 4201.055. HEALTH CARE SERVICE PROVIDED UNDER AUTOMOBILE INSURANCE POLICY....

Section 4201.056. Employee Welfare Benefit Plans - Sec. 4201.056. EMPLOYEE WELFARE BENEFIT PLANS. This chapter does not...

Section 4201.057. Health Maintenance Organizations - Sec. 4201.057. HEALTH MAINTENANCE ORGANIZATIONS. (a) In this section, "health...

Section 4201.058. Insurers - Sec. 4201.058. INSURERS. (a) This chapter applies to an insurer...

Subchapter C. Certification

Section 4201.101. Certificate of Registration Required - Sec. 4201.101. CERTIFICATE OF REGISTRATION REQUIRED. A utilization review agent...

Section 4201.102. Requirements for Certification - Sec. 4201.102. REQUIREMENTS FOR CERTIFICATION. (a) The commissioner may issue...

Section 4201.103. Certificate Renewal - Sec. 4201.103. CERTIFICATE RENEWAL. Certification may be renewed biennially by...

Section 4201.104. Certification and Renewal Forms - Sec. 4201.104. CERTIFICATION AND RENEWAL FORMS. (a) The commissioner shall...

Section 4201.105. Fees - Sec. 4201.105. FEES. The commissioner shall establish, administer, and enforce...

Section 4201.106. Certificate Not Transferable - Sec. 4201.106. CERTIFICATE NOT TRANSFERABLE. A certificate of registration is...

Section 4201.107. Reporting Material Changes - Sec. 4201.107. REPORTING MATERIAL CHANGES. A utilization review agent shall...

Section 4201.108. List of Utilization Review Agents - Sec. 4201.108. LIST OF UTILIZATION REVIEW AGENTS. (a) The commissioner...

Subchapter D. Utilization Review: General Standards

Section 4201.151. Utilization Review Plan - Sec. 4201.151. UTILIZATION REVIEW PLAN. A utilization review agent's utilization...

Section 4201.152. Utilization Review Under Physician - Sec. 4201.152. UTILIZATION REVIEW UNDER PHYSICIAN. A utilization review agent...

Section 4201.153. Screening Criteria and Review Procedures - Sec. 4201.153. SCREENING CRITERIA AND REVIEW PROCEDURES. (a) A utilization...

Section 4201.154. Review and Inspection of Screening Criteria and Review Procedures - Sec. 4201.154. REVIEW AND INSPECTION OF SCREENING CRITERIA AND REVIEW...

Section 4201.155. Limitation on Notice Requirements and Review Procedures - Sec. 4201.155. LIMITATION ON NOTICE REQUIREMENTS AND REVIEW PROCEDURES. (a)...

Subchapter E. Utilization Review: Relations With Patients and Health Care Providers

Section 4201.201. Repetitive Contacts With Health Care Provider or Patient; Frequency of Reviews - Sec. 4201.201. REPETITIVE CONTACTS WITH HEALTH CARE PROVIDER OR PATIENT;...

Section 4201.202. Observing or Participating in Patient's Care - Sec. 4201.202. OBSERVING OR PARTICIPATING IN PATIENT'S CARE. (a) Unless...

Section 4201.203. Mental Health Therapy - Sec. 4201.203. MENTAL HEALTH THERAPY. (a) A utilization review agent...

Section 4201.204. Complaint System - Sec. 4201.204. COMPLAINT SYSTEM. (a) A utilization review agent shall...

Section 4201.205. Designated Initial Contact - Sec. 4201.205. DESIGNATED INITIAL CONTACT. (a) A health care provider...

Section 4201.206. Opportunity to Discuss Treatment Before Adverse Determination - Sec. 4201.206. OPPORTUNITY TO DISCUSS TREATMENT BEFORE ADVERSE DETERMINATION. (a)...

Section 4201.207. Charges by Health Care Provider for Providing Medical Information - Sec. 4201.207. CHARGES BY HEALTH CARE PROVIDER FOR PROVIDING MEDICAL...

Subchapter F. Utilization Review: Personnel

Section 4201.251. Delegation of Utilization Review - Sec. 4201.251. DELEGATION OF UTILIZATION REVIEW. A utilization review agent...

Section 4201.252. Personnel - Sec. 4201.252. PERSONNEL. (a) Personnel employed by or under contract...

Section 4201.253. Prohibited Bases for Employment, Compensation, Evaluations, or Performance Standards - Sec. 4201.253. PROHIBITED BASES FOR EMPLOYMENT, COMPENSATION, EVALUATIONS, OR PERFORMANCE...

Subchapter G. Notice of Determinations

Section 4201.301. General Duty to Notify - Sec. 4201.301. GENERAL DUTY TO NOTIFY. A utilization review agent...

Section 4201.302. General Time for Notice - Sec. 4201.302. GENERAL TIME FOR NOTICE. A utilization review agent...

Section 4201.303. Adverse Determination: Contents of Notice - Sec. 4201.303. ADVERSE DETERMINATION: CONTENTS OF NOTICE. (a) Notice of...

Section 4201.304. Time for Notice of Adverse Determination - Sec. 4201.304. TIME FOR NOTICE OF ADVERSE DETERMINATION. (a) Subject...

Section 4201.305. Notice of Adverse Determination for Retrospective Utilization Review - Sec. 4201.305. NOTICE OF ADVERSE DETERMINATION FOR RETROSPECTIVE UTILIZATION REVIEW....

Subchapter H. Appeal of Adverse Determination

Section 4201.351. Complaint as Appeal - Sec. 4201.351. COMPLAINT AS APPEAL. For purposes of this subchapter,...

Section 4201.352. Written Description of Appeal Procedures - Sec. 4201.352. WRITTEN DESCRIPTION OF APPEAL PROCEDURES. A utilization review...

Section 4201.353. Appeal Procedures Must Be Reasonable - Sec. 4201.353. APPEAL PROCEDURES MUST BE REASONABLE. The procedures for...

Section 4201.354. Persons or Entities Who May Appeal - Sec. 4201.354. PERSONS OR ENTITIES WHO MAY APPEAL. The procedures...

Section 4201.355. Acknowledgment of Appeal - Sec. 4201.355. ACKNOWLEDGMENT OF APPEAL. (a) The procedures for appealing...

Section 4201.356. Decision by Physician Required; Specialty Review - Sec. 4201.356. DECISION BY PHYSICIAN REQUIRED; SPECIALTY REVIEW. (a) The...

Section 4201.357. Expedited Appeal for Denial of Emergency Care, Continued Hospitalization, Prescription Drugs or Intravenous Infusions - Sec. 4201.357. EXPEDITED APPEAL FOR DENIAL OF EMERGENCY CARE, CONTINUED...

Section 4201.358. Response Letter to Interested Persons - Sec. 4201.358. RESPONSE LETTER TO INTERESTED PERSONS. The procedures for...

Section 4201.359. Notice of Appeal - Sec. 4201.359. NOTICE OF APPEAL. (a) The procedures for appealing...

Section 4201.360. Immediate Appeal to Independent Review Organization in Life-Threatening Circumstances - Sec. 4201.360. IMMEDIATE APPEAL TO INDEPENDENT REVIEW ORGANIZATION IN LIFE-THREATENING...

Section 4201.3601. Immediate Appeal to Independent Review Organization for Denial of Prescription Drugs or Intravenous Infusions - Sec. 4201.3601. IMMEDIATE APPEAL TO INDEPENDENT REVIEW ORGANIZATION FOR DENIAL...

Subchapter I. Independent Review of Adverse Determination

Section 4201.401. Review by Independent Review Organization; Compliance With Independent Determination - Sec. 4201.401. REVIEW BY INDEPENDENT REVIEW ORGANIZATION; COMPLIANCE WITH INDEPENDENT...

Section 4201.402. Information Provided to Independent Review Organization - Sec. 4201.402. INFORMATION PROVIDED TO INDEPENDENT REVIEW ORGANIZATION. (a) Not...

Section 4201.403. Payment for Independent Review - Sec. 4201.403. PAYMENT FOR INDEPENDENT REVIEW. A utilization review agent...

Subchapter J. Specialty Utilization Review Agents

Section 4201.451. Definition - Sec. 4201.451. DEFINITION. For purposes of this subchapter, "specialty utilization...

Section 4201.452. Inapplicability of Certain Other Law - Sec. 4201.452. INAPPLICABILITY OF CERTAIN OTHER LAW. A specialty utilization...

Section 4201.453. Utilization Review Plan - Sec. 4201.453. UTILIZATION REVIEW PLAN. A specialty utilization review agent's...

Section 4201.454. Utilization Review Under Direction of Provider of Same Specialty - Sec. 4201.454. UTILIZATION REVIEW UNDER DIRECTION OF PROVIDER OF SAME...

Section 4201.455. Personnel - Sec. 4201.455. PERSONNEL. (a) Personnel who are employed by or...

Section 4201.456. Opportunity to Discuss Treatment Before Adverse Determination - Sec. 4201.456. OPPORTUNITY TO DISCUSS TREATMENT BEFORE ADVERSE DETERMINATION. Subject...

Section 4201.457. Appeal Decisions - Sec. 4201.457. APPEAL DECISIONS. A specialty utilization review agent shall...

Subchapter L. Confidentiality of Information; Access to Other Information

Section 4201.551. General Confidentiality Requirement - Sec. 4201.551. GENERAL CONFIDENTIALITY REQUIREMENT. (a) A utilization review agent...

Section 4201.552. Consent Requirements - Sec. 4201.552. CONSENT REQUIREMENTS. (a) A utilization review agent may...

Section 4201.553. Providing Information to Affiliated Entities - Sec. 4201.553. PROVIDING INFORMATION TO AFFILIATED ENTITIES. A utilization review...

Section 4201.554. Providing Information to Commissioner - Sec. 4201.554. PROVIDING INFORMATION TO COMMISSIONER. Notwithstanding this subchapter, a...

Section 4201.555. Access to Recorded Personal Information - Sec. 4201.555. ACCESS TO RECORDED PERSONAL INFORMATION. (a) If an...

Section 4201.556. Publishing Information Identifiable to Health Care Provider - Sec. 4201.556. PUBLISHING INFORMATION IDENTIFIABLE TO HEALTH CARE PROVIDER. (a)...

Section 4201.557. Requirement to Maintain Data in Confidential Manner - Sec. 4201.557. REQUIREMENT TO MAINTAIN DATA IN CONFIDENTIAL MANNER. A...

Section 4201.558. Destruction of Certain Confidential Documents - Sec. 4201.558. DESTRUCTION OF CERTAIN CONFIDENTIAL DOCUMENTS. When a utilization...

Subchapter M. Enforcement

Section 4201.601. Notice of Suspected Violation; Compelling Production of Information - Sec. 4201.601. NOTICE OF SUSPECTED VIOLATION; COMPELLING PRODUCTION OF INFORMATION....

Section 4201.602. Enforcement Proceeding - Sec. 4201.602. ENFORCEMENT PROCEEDING. (a) The commissioner may initiate a...

Section 4201.603. Remedies and Penalties for Violation - Sec. 4201.603. REMEDIES AND PENALTIES FOR VIOLATION. If the commissioner...

Subchapter N. Exemption From Preauthorization Requirements for Physicians and Providers Providing Certain Health Care Services

Section 4201.651. Definitions - Sec. 4201.651. DEFINITIONS. (a) In this subchapter, "preauthorization" means a...

Section 4201.652. Applicability of Subchapter - Sec. 4201.652. APPLICABILITY OF SUBCHAPTER. This subchapter applies only to:...

Section 4201.653. Exemption From Preauthorization Requirements for Physicians and Providers Providing Certain Health Care Services - Sec. 4201.653. EXEMPTION FROM PREAUTHORIZATION REQUIREMENTS FOR PHYSICIANS AND PROVIDERS...

Section 4201.654. Duration of Preauthorization Exemption - Sec. 4201.654. DURATION OF PREAUTHORIZATION EXEMPTION. (a) A physician's or...

Section 4201.655. Denial or Rescission of Preauthorization Exemption - Sec. 4201.655. DENIAL OR RESCISSION OF PREAUTHORIZATION EXEMPTION. (a) A...

Section 4201.656. Independent Review of Exemption Determination - Sec. 4201.656. INDEPENDENT REVIEW OF EXEMPTION DETERMINATION. (a) A physician...

Section 4201.657. Effect of Appeal or Independent Review Determination - Sec. 4201.657. EFFECT OF APPEAL OR INDEPENDENT REVIEW DETERMINATION. (a)...

Section 4201.658. Eligibility for Preauthorization Exemption Following Finalized Exemption Rescission or Denial - Sec. 4201.658. ELIGIBILITY FOR PREAUTHORIZATION EXEMPTION FOLLOWING FINALIZED EXEMPTION RESCISSION...

Section 4201.659. Effect of Preauthorization Exemption - Sec. 4201.659. EFFECT OF PREAUTHORIZATION EXEMPTION. (a) A health maintenance...

Chapter 4202 - Independent Review Organizations

Section 4202.001. Definition - Sec. 4202.001. DEFINITION. In this chapter, "payor" has the meaning...

Section 4202.002. Adoption of Standards for Independent Review Organizations - Sec. 4202.002. ADOPTION OF STANDARDS FOR INDEPENDENT REVIEW ORGANIZATIONS. (a)...

Section 4202.003. Requirements Regarding Timeliness of Determination - Sec. 4202.003. REQUIREMENTS REGARDING TIMELINESS OF DETERMINATION. The standards adopted...

Section 4202.004. Certification - Sec. 4202.004. CERTIFICATION. (a) To be certified as an independent...

Section 4202.005. Periodic Reporting of Information; Biennial Designation; Updates and Inspection - Sec. 4202.005. PERIODIC REPORTING OF INFORMATION; BIENNIAL DESIGNATION; UPDATES AND...

Section 4202.006. Payors Fees - Sec. 4202.006. PAYORS FEES. The commissioner shall charge payors fees...

Section 4202.007. Oversight - Sec. 4202.007. OVERSIGHT. The commissioner shall provide ongoing oversight of...

Section 4202.008. Prohibited Ownership or Control of Independent Review Organization - Sec. 4202.008. PROHIBITED OWNERSHIP OR CONTROL OF INDEPENDENT REVIEW ORGANIZATION....

Section 4202.009. Confidential Information - Sec. 4202.009. CONFIDENTIAL INFORMATION. Information that reveals the identity of...

Section 4202.010. Immunity From Liability - Sec. 4202.010. IMMUNITY FROM LIABILITY. (a) An independent review organization...

Section 4202.012. Referral - Sec. 4202.012. REFERRAL. The commissioner by rule shall require referral...

Section 4202.013. Primary Office in This State Required - Sec. 4202.013. PRIMARY OFFICE IN THIS STATE REQUIRED. An independent...

Section 4202.014. Preemption - Sec. 4202.014. PREEMPTION. The commissioner shall suspend enforcement of any...

Chapter 4203 - Prohibited Consultant Activities

Section 4203.001. Definition - Sec. 4203.001. DEFINITION. In this chapter, "consultant" means a person...

Section 4203.002. Prohibited Consultant Activities - Sec. 4203.002. PROHIBITED CONSULTANT ACTIVITIES. A member or employee of...

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Texas Statutes Insurance Code Title 14 - Utilization Review and Independent Review

Texas Statutes
Insurance Code
Title 14 - Utilization Review and Independent Review