Texas Insurance Code - Not Codified - Article 21.58A. Health Care Utilization Review Agents
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Art. 21.58A. HEALTH CARE UTILIZATION REVIEW AGENTS.
Article repealed effective April 1, 2007
Purpose
Sec. 1. The purpose of this article is to:
(1) promote the delivery of quality health care in a
cost-effective manner;
(2) assure that utilization review agents adhere to
reasonable standards for conducting utilization reviews;
(3) foster greater coordination and cooperation between
health care providers and utilization review agents;
(4) improve communications and knowledge of benefits among
all parties concerned before expenses are incurred; and
(5) ensure that utilization review agents maintain the
confidentiality of medical records in accordance with applicable
law.
Definitions
Sec. 2. In this article:
(1) "Administrative procedure act" means Chapter 2001,
Government Code.
(2) "Administrator" means a person holding a certificate of
authority under Article 21.07-6 of this code.
(3) "Adverse determination" means a determination by a
utilization review agent that the health care services furnished or
proposed to be furnished to a patient are not medically necessary.
(4) "Certificate" means a certificate of registration
granted by the commissioner to a utilization review agent.
(5) "Commissioner" means the commissioner of insurance.
(6) "Emergency care" means health care services provided in
a hospital emergency facility or comparable facility to evaluate
and stabilize medical conditions of a recent onset and severity,
including but not limited to severe pain, that would lead a prudent
layperson possessing an average knowledge of medicine and health to
believe that his or her condition, sickness, or injury is of such a
nature that failure to get immediate medical care could result in:
(A) placing the patient's health in serious jeopardy;
(B) serious impairment to bodily functions;
(C) serious dysfunction of any bodily organ or part;
(D) serious disfigurement; or
(E) in the case of a pregnant woman, serious jeopardy to the
health of the fetus.
(7) "Dental plan" means an insurance policy or health
benefit plan, including a policy written by a company subject to
Chapter 20 of this code, that provides coverage for expenses for
dental services.
(8) "Enrollee" means a person covered by a health insurance
policy or plan and includes a person who is covered as an eligible
dependent of another person.
(9) "Health benefit plan" means a plan of benefits that
defines the coverage provisions for health care for enrollees
offered or provided by any organization, public or private, other
than health insurance.
(10) "Health care provider" means any person, corporation,
facility, or institution licensed by a state to provide or
otherwise lawfully providing health care services that is eligible
for independent reimbursement for those services.
(11) "Health insurance policy" means an insurance policy,
including a policy written by a company subject to Chapter 20 of
this code, that provides coverage for medical or surgical expenses
incurred as a result of accident or sickness.
(12) "Life threatening" means a disease or condition for
which the likelihood of death is probable unless the course of the
disease or condition is interrupted.
(13) "Nurse" means a professional or registered nurse, a
licensed vocational nurse, or a licensed practical nurse.
(14) "Open meetings law" means Chapter 551, Government Code
.
(15) "Open records law" means Chapter 552, Government Code.
(16) "Patient" means the enrollee or an eligible dependent
of the enrollee under a health benefit plan or health insurance
plan.
(17) "Payor" means:
(A) an insurer writing health insurance policies;
(B) any preferred provider organization, health maintenance
organization, self-insurance plan; or
(C) any other person or entity which provides, offers to
provide, or administers hospital, outpatient, medical, or other
health benefits to persons treated by a health care provider in this
state pursuant to any policy, plan, or contract.
(18) "Physician" means a licensed doctor of medicine or a
doctor of osteopathy.
(19) "Provider of record" means the physician or other
health care provider that has primary responsibility for the care,
treatment, and services rendered to the enrollee and includes any
health care facility when treatment is rendered on an inpatient or
outpatient basis.
(20) "Utilization review" means a system for prospective or
concurrent review of the medical necessity and appropriateness of
health care services being provided or proposed to be provided to an
individual within this state. Utilization review shall not include
elective requests for clarification of coverage.
(21) "Utilization review agent" means an entity that
conducts utilization review for:
(A) an employer with employees in this state who are covered
under a health benefit plan or health insurance policy;
(B) a payor; or
(C) an administrator.
(22) "Utilization review plan" means the screening criteria
and utilization review procedures of a utilization review agent.
(23) "Working day" means a weekday, excluding a legal
holiday.
Certification
Sec. 3. (a) A utilization review agent may not conduct
utilization review of health care provided in this state unless the
commissioner has granted the utilization review agent a certificate
pursuant to this article.
(b) The commissioner may only issue a certificate to an
applicant that has met all the requirements of this article and all
applicable rules and regulations of the commissioner.
(c) A certificate issued under this article is not
transferable.
(d) Certification may be renewed biennially by filing, not
later than March 1, a renewal form with the commissioner
accompanied by a renewal fee in an amount set by the commissioner.
(e) The commissioner shall promulgate certification and
renewal forms to be filed under this section. The form for initial
certification must require the following:
(1) the entity's name, address, telephone number, and
normal business hours;
(2) the name and address of an agent for service of process
in this state;
(3) a summary of the utilization review plan, but in no
event shall proprietary details be subject to inclusion in the
summary;
(4) information concerning the personnel categories that
will perform utilization review for the utilization review agent;
(5) a copy of the procedure established by the utilization
review agent as required by this article for appeal of an adverse
determination;
(6) a certification that the utilization review agent will
comply with the provisions of this article; and
(7) a copy of the procedures for handling oral and written
complaints by enrollees, patients, or health care providers.
(f) The commissioner shall establish, administer, and
enforce the certification and renewal fees under this section in
amounts not greater than that necessary to cover the cost of
administration of this article.
(g) A utilization review agent shall report any material
changes in the information in a certification or renewal form filed
under this section not later than the 30th day after the date on
which the change takes effect.
Standards for utilization review
Sec. 4. (a) As a condition of certification or renewal
thereof, a utilization review agent shall be required to maintain
compliance with the provisions of this section.
(b) The utilization review plan, including reconsideration
and appeal requirements, shall be reviewed by a physician and
conducted in accordance with standards developed with input from
appropriate health care providers and approved by a physician.
(c) Personnel employed by or under contract with the
utilization review agent to perform utilization review shall be
appropriately trained and qualified. Personnel who obtain
information regarding a patient's specific medical condition,
diagnosis, and treatment options or protocols directly from the
physician or health care provider, either orally or in writing, and
who are not physicians shall be nurses, physician assistants, or
health care providers qualified to provide the service requested by
the provider. This provision shall not be interpreted to require
such qualifications for personnel who perform clerical or
administrative tasks.
(d) A utilization review agent shall not set or impose any
notice or other review procedures contrary to the requirements of
the health insurance policy or health benefit plan.
(e) Unless approved for an individual patient by the
provider of record or modified by contract, a utilization review
agent shall be prohibited from observing, participating in, or
otherwise being present during a patient's examination, treatment,
procedure, or therapy. In no event shall this section otherwise be
construed to limit or deny contact with a patient for purposes of
conducting utilization review unless otherwise specifically
prohibited by law.
(f) A utilization review agent may not permit or provide
compensation or any thing of value to its employees or agents,
condition employment of its employee or agent evaluations, or set
its employee or agent performance standards, based on the amount of
volume of adverse determinations, reductions or limitations on
lengths of stay, benefits, services, or charges or on the number or
frequency of telephone calls or other contacts with health care
providers or patients, which are inconsistent with the provisions
of this article.
(g) A health care provider may designate one or more
individuals as the initial contact or contacts for utilization
review agents seeking routine information or data. In no event
shall the designation of such an individual or individuals preclude
a utilization review agent or medical advisor from contacting a
health care provider or others in his or her employ where a review
might otherwise be unreasonably delayed or where the designated
individual is unable to provide the necessary information or data
requested by the utilization review agent.
(h) Utilization review conducted by a utilization review
agent shall be under the direction of a physician licensed to
practice medicine by a state licensing agency in the United States.
(i) Each utilization review agent shall utilize written
medically acceptable screening criteria and review procedures
which are established and periodically evaluated and updated with
appropriate involvement from physicians, including practicing
physicians, dentists, and other health care providers. Utilization
review decisions shall be made in accordance with currently
accepted medical or health care practices, taking into account
special circumstances of each case that may require deviation from
the norm stated in the screening criteria. Screening criteria must
be objective, clinically valid, compatible with established
principles of health care, and flexible enough to allow deviations
from the norms when justified on a case-by-case basis. Screening
criteria must be used to determine only whether to approve the
requested treatment. Denials must be referred to an appropriate
physician, dentist, or other health care provider to determine
medical necessity. Such written screening criteria and review
procedures shall be available for review and inspection to
determine appropriateness and compliance as deemed necessary by the
commissioner and copying as necessary for the commissioner to carry
out his or her lawful duties under this code, provided, however,
that any information obtained or acquired under the authority of
this subsection and article is confidential and privileged and not
subject to the open records law or subpoena except to the extent
necessary for the commissioner to enforce this article.
(j) A utilization review agent may not engage in unnecessary
or unreasonable repetitive contacts with the health care provider
or patient and shall base the frequency of contacts or reviews on
the severity or complexity of the patient's condition or on
necessary treatment and discharge planning activity.
(k) Subject to the notice requirements of Section 5 of this
article, in any instance where the utilization review agent is
questioning the medical necessity or appropriateness of health care
services, the health care provider who ordered the services shall
be afforded a reasonable opportunity to discuss the plan of
treatment for the patient and the clinical basis for the
utilization review agent's decision with a physician prior to
issuance of an adverse determination.
(l) Unless precluded or modified by contract, a utilization
review agent shall reimburse health care providers for the
reasonable costs for providing medical information in writing,
including copying and transmitting any requested patient records or
other documents. A health care provider's charges for providing
medical information to a utilization review agent shall not exceed
the cost of copying set by rule of the commissioner of workers'
compensation for records regarding a workers' compensation claim
and may not include any costs that are otherwise recouped as a part
of the charge for health care.
(m) A utilization review agent shall establish and maintain
a complaint system that provides reasonable procedures for the
resolution of oral or written complaints initiated by enrollees,
patients, or health care providers concerning the utilization
review and shall maintain records of such complaints for three
years from the time the complaints are filed. The complaint
procedure shall include a written response to the complainant by
the agent within 30 days. The utilization review agent shall submit
to the commissioner a summary report of all complaints at such times
and in such forms as the commissioner may require and shall permit
the commissioner to examine the complaints and all relevant
documents at any time.
(n) The utilization review agent may delegate utilization
review to qualified personnel in the hospital or health care
facility where the health care services were or are to be provided.
However, such delegation shall not relieve the utilization review
agent of full responsibility for compliance with this article,
including the conduct of those to whom utilization review has been
delegated.
(o) A utilization review agent may not require, as a
condition of treatment approval or for any other reason, the
observation of a psychotherapy session or the submission or review
of a mental health therapist's process or progress notes.
Notwithstanding this subsection, a utilization review agent may
require submission of a patient's medical record summary.
Notice of determinations made by utilization review agents
Sec. 5. (a) A utilization review agent shall notify the
enrollee or a person acting on behalf of the enrollee and the
enrollee's provider of record of a determination made in a
utilization review.
(b) The notification required by this section must be mailed
or otherwise transmitted not later than two working days after the
date of the request for utilization review and all information
necessary to complete the review is received by the agent.
(c) In the event of an adverse determination, the
notification by the utilization review agent must include:
(1) the principal reasons for the adverse determination;
(2) the clinical basis for the adverse determination;
(3) a description or the source of the screening criteria
that were utilized as guidelines in making the determination; and
(4) a description of the procedure for the complaint and
appeal process, including:
(A) notification to the enrollee of the enrollee's right to
appeal an adverse determination to an independent review
organization;
(B) notification to the enrollee of the procedures for
appealing an adverse determination to an independent review
organization; and
(C) notification to an enrollee who has a life-threatening
condition of the enrollee's right to an immediate review by an
independent review organization and the procedures to obtain that
review.
(d) The notification of adverse determination required by
this section shall be provided by the utilization review agent:
(1) within one working day by telephone or electronic
transmission to the provider of record in the case of a patient who
is hospitalized at the time of the adverse determination, to be
followed by a letter notifying the patient and the provider of
record of an adverse determination within three working days;
(2) within three working days in writing to the provider of
record and the patient if the patient is not hospitalized at the
time of the adverse determination; or
(3) within the time appropriate to the circumstances
relating to the delivery of the services and the condition of the
patient, but in no case to exceed one hour from notification when
denying poststabilization care subsequent to emergency treatment
as requested by a treating physician or provider. In such
circumstances, notification shall be provided to the treating
physician or health care provider.
Appeal of Adverse Determinations of Utilization Review Agents
Sec. 6. (a) A utilization review agent shall maintain and
make available a written description of appeal procedures involving
an adverse determination. For the purposes of this section, a
complaint filed concerning dissatisfaction or disagreement with an
adverse determination constitutes an appeal of that adverse
determination.
(b) The procedures for appeals must be reasonable and must
include the following:
(1) a provision that an enrollee, a person acting on behalf
of the enrollee, or the enrollee's physician or health care
provider may appeal the adverse determination orally or in writing;
(2) a provision that, within five working days from receipt
of the appeal, the utilization review agent shall send to the
appealing party a letter acknowledging the date of the utilization
review agent's receipt of the appeal. The letter must also include
the provisions listed in this subsection and a list of the documents
that the appealing party must submit for review by the utilization
review agent. When the utilization review agent receives an oral
appeal of adverse determination, the utilization review agent shall
send a one-page appeal form to the appealing party;
(3) a provision that appeal decisions shall be made by a
physician, provided that, if the appeal is denied and within 10
working days the health care provider sets forth in writing good
cause for having a particular type of a specialty provider review
the case, the denial shall be reviewed by a health care provider in
the same or similar specialty as typically manages the medical or
dental condition, procedure, or treatment under discussion for
review of the adverse determination, and that specialty review
shall be completed within 15 working days of receipt of the request;
(4) in addition to the written appeal, a method for an
expedited appeal procedure for emergency care denials and denials
of continued stays for hospitalized patients. That procedure must
include a review by a health care provider who has not previously
reviewed the case and who is of the same or a similar specialty as
typically manages the medical condition, procedure, or treatment
under review. The time frame in which the appeal must be completed
shall be based on the medical or dental immediacy of the condition,
procedure, or treatment, but may not exceed one working day from the
date all information necessary to complete the appeal is received;
(5) a provision that after the utilization review agent has
sought review of the appeal of the adverse determination, the
utilization review agent shall issue a response letter to the
patient or a person acting on behalf of the patient, and the
patient's physician or health care provider, explaining the
resolution of the appeal; and
(6) written notification to the appealing party of the
determination of the appeal, as soon as practical, but in no case
later than the 30th calendar day after the date the utilization
agent receives the appeal. If the appeal is denied, the written
notification shall include a clear and concise statement of:
(A) the clinical basis for the appeal's denial;
(B) the specialty of the physician or other health care
provider making the denial; and
(C) notice of the appealing party's right to seek review of
the denial by an independent review organization under Section 6A
of this article and the procedures for obtaining that review.
(c) Notwithstanding this article or any other law, in a
circumstance involving an enrollee's life-threatening condition,
the enrollee is entitled to an immediate appeal to an independent
review organization as provided by Section 6A of this article and is
not required to comply with procedures for an internal review of the
utilization review agent's adverse determination.
Independent review of adverse determinations
Sec. 6A. A utilization review agent shall:
(1) permit any party whose appeal of an adverse
determination is denied by the utilization review agent to seek
review of that determination by an independent review organization
assigned to the appeal in accordance with Article 21.58C of this
code;
(2) provide to the appropriate independent review
organization not later than the third business day after the date
that the utilization review agent receives a request for review a
copy of:
(A) any medical records of the enrollee that are relevant to
the review;
(B) any documents used by the plan in making the
determination to be reviewed by the organization;
(C) the written notification described by Section 6(b)(5)
of this article;
(D) any documentation and written information submitted to
the utilization review agent in support of the appeal; and
(E) a list of each physician or health care provider who has
provided care to the enrollee and who may have medical records
relevant to the appeal;
(3) comply with the independent review organization's
determination with respect to the medical necessity or
appropriateness of health care items and services for an enrollee;
and
(4) pay for the independent review.
Telephone access
Sec. 7. (a) A utilization review agent shall have appropriate
personnel reasonably available by toll-free telephone at least 40
hours per week during normal business hours in Texas to discuss
patients' care and allow response to telephone review requests.
(b) A utilization review agent must have a telephone system
capable of accepting or recording or providing instructions to
incoming phone calls during other than normal business hours and
shall respond to such calls not later than two working days of the
later of the date on which the call was received or the date the
details necessary to respond have been received from the caller.
(c) A utilization review agent must provide a written
description to the commissioner setting forth the procedures to be
used when responding to poststabilization care subsequent to
emergency treatment as requested by a treating physician or health
care provider.
Confidentiality
Sec. 8. (a) A utilization review agent shall preserve the
confidentiality of individual medical records to the extent
required by law.
(b) A utilization review agent may not disclose or publish
individual medical records, personal information, or other
confidential information about a patient obtained in the
performance of utilization review without the prior written consent
of the patient or as otherwise required by law. If such
authorization is submitted by anyone other than the individual who
is the subject of the personal or confidential information
requested, such authorization must:
(1) be dated; and
(2) contain the signature of the individual who is the
subject of the personal or confidential information requested. The
signature must have been obtained one year or less prior to the date
the disclosure is sought or the authorization is invalid.
(c) A utilization review agent may provide confidential
information to a third party under contract or affiliated with the
utilization review agent for the sole purpose of performing or
assisting with utilization review. Information provided to third
parties shall remain confidential.
(d) If an individual submits a written request to the
utilization review agent for access to recorded personal
information about the individual, the utilization review agent
shall within 10 business days from the date such request is
received:
(1) inform the individual submitting the request of the
nature and substance of the recorded personal information in
writing; and
(2) permit the individual to see and copy, in person, the
recorded personal information pertaining to the individual or to
obtain a copy of the recorded personal information by mail, at the
discretion of the individual, unless the recorded personal
information is in coded form, in which case an accurate translation
in plain language shall be provided in writing.
(e) A utilization review agent's charges for providing a
copy of recorded personal information to individuals shall be
reasonable, as determined by rule of the commissioner, and may not
include any costs that are otherwise recouped as part of the charge
for utilization review.
Text of subsec. (f) as added by Acts 1997, 75th Leg., ch. 163, Sec. 1
(f) Confidential information in the custody of a
utilization review agent may be provided to an independent review
organization, subject to rules and standards adopted by the
commissioner under Article 21.58C of this code.
Text of subsec. (f) as added by Acts 1997, 75th Leg., ch. 1025, Sec.
7
(f) The utilization review agent may not publish data which
identifies a particular physician or health care provider,
including any quality review studies or performance tracking data,
without prior written notice to the involved provider. This
prohibition does not apply to internal systems or reports used by
the utilization review agent.
(g) Documents in the custody of the utilization review agent
that contain confidential patient information or physician or
health care provider financial data shall be destroyed by a method
which induces complete destruction of the information when the
agent determines the information is no longer needed.
(h) All patient, physician, and health care provider data
shall be maintained by the utilization review agent in a
confidential manner which prevents unauthorized disclosure to
third parties. Nothing in this article shall be construed to allow
a utilization review agent to take actions that violate a state or
federal statute or regulation concerning confidentiality of
patient records.
(i) Notwithstanding the provisions in Subsections (a)
through (h) of this section, the utilization review agent shall
provide to the commissioner on request individual medical records
or other confidential information for determination of compliance
with this article. The information is confidential and privileged
and is not subject to the open records law, Chapter 552, Government
Code, or to subpoena, except to the extent necessary to enable the
commissioner to enforce this article.
Violations
Sec. 9. (a) If the commissioner believes that any person or
entity conducting utilization review pursuant to this article is in
violation of this article or applicable regulations, the
commissioner shall notify the utilization review agent, health
maintenance organization, or insurer of the alleged violation and
may compel the production of any and all documents or other
information as necessary in order to determine whether or not such
violation has taken place.
(b) The commissioner may initiate the proceedings under
this section.
(c) Proceedings under this article are a contested case for
the purposes of the administrative procedure act.
(d) If the commissioner determines that the utilization
review agent, health maintenance organization, insurer, or other
person or entity conducting utilization review pursuant to this
article has violated or is violating any provision of this article,
the commissioner may:
(1) impose sanctions under Section 7, Article 1.10 of this
code;
(2) issue a cease and desist order under Article 1.10A of
this code; or
(3) assess administrative penalties under Article 1.10E of
this code.
Sec. 10. Repealed by Acts 2001, 77th Leg., ch. 703, Sec.
8.01(18), eff. Sept. 1, 2001.
Claims reviews of medical necessity
Sec. 11. (a) When a retrospective review of the medical
necessity and appropriateness of health care service is made under
a health insurance policy or plan: (1) such retrospective review
shall be based on written screening criteria established and
periodically updated with appropriate involvement from physicians,
including practicing physicians, and other health care providers;
and (2) the payor's system for such retrospective review of medical
necessity and appropriateness shall be under the direction of a
physician.
(b) When an adverse determination is made under a health
insurance policy or plan based on a retrospective review of the
medical necessity and appropriateness of the allocation of health
care resources and services, the payor shall afford the health care
providers the opportunity to appeal the determination in the same
manner afforded the enrollee, with the enrollee's consent to act on
his or her behalf, but in no event shall health care providers be
precluded from appeal if the enrollee is not reasonably available
or competent to consent. Such appeal shall not be construed to
imply or confer on such health care providers any contract rights
with respect to the enrollee's health insurance policy or plan that
the health care provider does not otherwise have.
Lists of utilization review agents
Sec. 12. The commissioner shall maintain and update monthly a
list of utilization review agents issued certificates and the
renewal date for those certificates. The commissioner shall
provide the list at cost to all individuals or organizations
requesting the list.
Authority to Adopt Rules
Sec. 13. The commissioner may have the authority to adopt
rules and regulations to implement the provisions of this article.
The commissioner shall appoint an advisory committee to advise the
commissioner in developing rules and regulations to administer this
article as authorized by Section 2001.031, Government Code. The
committee's deliberations shall be subject to the open meetings
law. The committee shall include the public counsel and one
representative for each of the following: insurance companies,
health maintenance organizations, group hospital service
corporations, utilization review agents, employers, consumer
organizations, physicians, dentists, hospitals, registered nurses,
and other health care providers.
Application
Sec. 14. (a) This article shall not apply to a person who
provides information to enrollees about scope of coverage or
benefits provided under a health insurance policy or health benefit
plan and who does not determine whether particular health care
services provided or to be provided to an enrollee are medically
necessary or appropriate.
(b)(1) This article shall not apply to any contract with the
federal government for utilization review of patients eligible for
services under Title XVIII or XIX of the Social Security Act (42
U.S.C. Section 1395 et seq. or Section 1396 et seq.).
(2) Except as provided by Subsection (g) of this section,
this article shall not apply to the Texas Medicaid Program, the
services program for children with special health care needs
created pursuant to Chapter 35, Health and Safety Code, any program
administered under Title 2, Human Resources Code, any program of
the Texas Department of Mental Health and Mental Retardation, or
any program of the Texas Department of Criminal Justice.
(c) Except as otherwise provided by this subsection, this
article applies to utilization review of health care services
provided to persons eligible for workers' compensation medical
benefits under Title 5, Labor Code. The commissioner of workers'
compensation shall regulate in the manner provided by this article
a person who performs review of a medical benefit provided under
Title 5, Labor Code. In the event of a conflict between this
article and Title 5, Labor Code, Title 5, Labor Code, prevails. The
commissioner of workers' compensation may adopt rules as necessary
to implement this subsection.
(d) This article shall not apply to utilization review of
health care services provided under a policy or contract of
automobile insurance promulgated by the board under Subchapter A,
Chapter 5 of this code or issued pursuant to Article 1.14-2 of this
code.
(e) This article shall not apply to the terms or benefits of
employee welfare benefit plans as defined in Section 3(1) of the
Employee Retirement Income Security Act of 1974 (29 U.S.C. Section
1002(1) ).
(f) Any regulations promulgated pursuant to this article
shall relate only to persons or entities subject to this article.
(g) A health maintenance organization, including a health
maintenance organization that contracts with the Health and Human
Services Commission or an agency operating part of the state
Medicaid managed care program to provide health care services to
recipients of medical assistance under Chapter 32, Human Resources
Code, is subject to this article except as expressly provided in
this subsection and Subsection (i) of this section. If such health
maintenance organization performs utilization review as defined
herein, it shall, as a condition of licensure:
(1) comply with this article, except Sections 3 and 10, and
the commissioner shall promulgate rules for appropriate
verification and enforcement of compliance. However, nothing in
this article shall be construed to prohibit or limit the
distribution of a proportion of the savings from the reduction or
elimination of unnecessary medical services, treatment, supplies,
confinements, or days of confinement in a health care facility
through profit sharing, bonus, or withhold arrangements to
participating physicians or participating health care providers
for rendering health care services to enrollees; and
(2) submit to assessment of maintenance taxes under Article
20A.33, Texas Health Maintenance Organization Act (Article 20A.33,
Vernon's Texas Insurance Code), to cover the costs of administering
compliance of health maintenance organizations under this section.
(h) An insurer which delivers or issues for delivery a
health insurance policy in Texas and is subject to this code is
subject to this article except as expressly provided in this
subsection and Subsection (i) of this section. If an insurer
performs utilization review as defined herein it shall, as a
condition of licensure, comply with this article, except Sections 3
and 10, and the commissioner shall promulgate rules for appropriate
verification and enforcement of compliance. Such insurers shall be
subject to assessment of maintenance tax under Article 4.17 of this
code to cover the costs of administering compliance of insurers
under this section.
(i) However, when an insurer subject to this code or a
health maintenance organization performs utilization review for a
person or entity subject to this article other than one for which it
is the payor, such insurer or health maintenance organization shall
be required to obtain a certificate under Section 3 of this article
and comply with all the provisions of this article.
(j) A specialty utilization review agent is not subject to
Section 4(b), (c), (h), or (k) or Section 6(b)(3) of this article.
For purposes of this subsection, a specialty utilization review
agent means a utilization review agent that conducts utilization
review for specialty health care services, including but not
limited to dentistry, chiropractic, or physical therapy. A
specialty utilization review agent shall comply with the following
requirements:
(1) the utilization review plan, including reconsideration
and appeal requirements, shall be reviewed by a health care
provider of the appropriate specialty and conducted in accordance
with standards developed with input from a health care provider of
the appropriate specialty;
(2) personnel employed by or under contract with a specialty
utilization review agent to perform utilization review shall be
appropriately trained and qualified. Personnel who obtain
information directly from the physician or health care provider,
either orally or in writing, shall be nurses, physician assistants,
or other health care providers of the same specialty as the
utilization review agent and who are licensed or otherwise
authorized to provide the specialty health care service by a state
licensing agency in the United States, except that this provision
does not require those qualifications for personnel who perform
solely clerical or administrative tasks;
(3) utilization review conducted by a specialty utilization
review agent shall be conducted under the direction of a health care
provider of the same specialty and shall be licensed or otherwise
authorized to provide the specialty health care service by a state
licensing agency in the United States;
(4) subject to the notice requirements of Section 5 of this
article, in any instance where the specialty utilization review
agent questions the medical necessity or appropriateness of health
care services, the health care provider who ordered the services
shall, prior to the issuance of an adverse determination, be
afforded a reasonable opportunity to discuss the plan of treatment
for the patient and the clinical basis for the decision of the
utilization review agent with a health care provider of the same
specialty as the utilization review agent; and
(5) appeal decisions shall be made by a physician or health
care provider in the same or a similar specialty as typically
manages the medical, dental, or specialty condition, procedure, or
treatment under discussion for review of the adverse determination.
Added by Acts 1991, 72nd Leg., ch. 242, Sec. 11.03(a), eff. Sept. 1,
1991. Sec. 2 amended by Acts 1997, 75th Leg., ch. 1025, Sec. 1, eff.
Sept. 1, 1997; Sec. 3(b), (d), (e), (f) amended by Acts 1997, 75th
Leg., ch. 1025, Sec. 2, eff. Sept. 1, 1997; Sec. 4(c), (h), (i),
(k), (m), (n) amended by Acts 1997, 75th Leg., ch. 1025, Sec. 3,
eff. Sept. 1, 1997; Sec. 5(c), (d) amended by Acts 1997, 75th Leg.,
ch. 1025, Sec. 4, eff. Sept. 1, 1997; Sec. 6 amended by Acts 1997,
75th Leg., ch. 1025, Sec. 5, eff. Sept. 1, 1997; Sec. 6(b), (c),
amended by Acts 1997, 75th Leg., ch. 163, Sec. 2, eff. Sept. 1,
1997; Sec. 6A added by Acts 1997, 75th Leg., ch. 163, Sec. 3, eff.
Sept. 1, 1997; Sec. 7(c) added by Acts 1997, 75th Leg., ch. 1025,
Sec. 6, eff. Sept. 1, 1997; Sec. 8 amended by Acts 1997, 75th Leg.,
ch. 1025, Sec. 7, eff. Sept. 1, 1997; Sec. 8(f) added by Acts 1997,
75th Leg., ch. 163, Sec. 4, eff. Sept. 1, 1997; Sec. 9(a), (b), (d)
amended by Acts 1997, 75th Leg., ch. 1025, Sec. 8, eff. Sept. 1,
1997; Sec. 13 amended by Acts 1997, 75th Leg., ch. 1025, Sec. 9,
eff. Sept. 1, 1997; Sec. 14(b) amended by Acts 1997, 75th Leg., ch.
1025, Sec. 10, eff. Sept. 1, 1997; Sec. 14(c) amended by Acts 1997,
75th Leg., ch. 903, Sec. 1, eff. Sept. 1, 1997; Sec. 14(e), (g), (h)
amended by Acts 1997, 75th Leg., ch. 1025, Sec. 10, eff. Sept. 1,
1997; Sec. 14(j) added by Acts 1997, 75th Leg., ch. 1025, Sec. 10,
eff. Sept. 1, 1997; Sec. 4(o) added by Acts 1999, 76th Leg., ch.
579, Sec. 1, eff. Sept. 1, 1999; Sec. 5(a), (c) amended by Acts
1999, 76th Leg., ch. 1456, Sec. 1, eff. Sept. 1, 1999; Sec. 6(a)
amended by Acts 1999, 76th Leg., ch. 1456, Sec. 2, eff. Sept. 1,
1999; Sec. 6(b) amended by Acts 1999, 76th Leg., ch. 1456, Sec. 3,
eff. Sept. 1, 1999; Sec. 6(c) amended by Acts 1999, 76th Leg., ch.
1456, Sec. 4, eff. Sept. 1, 1999; Sec. 14(b)(2) amended by Acts
1999, 76th Leg., ch. 1505, Sec. 3.13, eff. Sept. 1, 1999; Sec. 10
repealed by Acts 2001, 77th Leg., ch. 703, Sec. 8.01(18), eff. Sept.
1, 2001; Sec. 4(l) amended by Acts 2005, 79th Leg., ch. 265, Sec.
6.071, eff. Sept. 1, 2005; Sec. 14(c) amended by Acts 2005, 79th
Leg., ch. 265, Sec. 6.072, eff. Sept. 1, 2005.
Article: 21.49A-1 21.49B 21.49C 21.50 21.52B 21.53X 21.54 21.58A 21.58B 21.58C 21.61 21.70 21.72 21.77 21.79
Last modified: August 11, 2007
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