Texas Insurance Code - Not Codified - Article 21.58C. Standards For Independent Review Organizations
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Art. 21.58C. STANDARDS FOR INDEPENDENT REVIEW
ORGANIZATIONS.
Article repealed effective April 1, 2007
Definitions
Sec. 1. In this article:
(1) "Life-threatening condition" has the meaning assigned
by Section 6, Article 21.58A of this code.
(2) "Payor" has the meaning assigned by Section 2, Article
21.58A of this code.
Certification and designation of independent review organizations
Sec. 2. (a) The commissioner shall:
(1) promulgate standards and rules for:
(A) the certification, selection, and operation of
independent review organizations to perform independent review
described by Section 6, Article 21.58A of this code; and
(B) the suspension and revocation of the certification;
(2) designate annually each organization that meets the
standards as an independent review organization;
(3) charge payors fees in accordance with this article as
necessary to fund the operations of independent review
organizations; and
(4) provide ongoing oversight of the independent review
organizations to ensure continued compliance with this article and
the standards and rules adopted under this article.
(b) The standards required by Subsection (a)(1) of this
section must ensure:
(1) the timely response of an independent review
organization selected under this article;
(2) the confidentiality of medical records transmitted to
an independent review organization for use in independent reviews;
(3) the qualifications and independence of each health care
provider or physician making review determinations for an
independent review organization;
(4) the fairness of the procedures used by an independent
review organization in making the determinations; and
(5) timely notice to enrollees of the results of the
independent review, including the clinical basis for the
determination.
(c) The standards adopted under Subsection (a)(1) of this
section must include standards that require each independent review
organization to make its determination:
(1) not later than the earlier of:
(A) the 15th day after the date the independent review
organization receives the information necessary to make the
determination; or
(B) the 20th day after the date the independent review
organization receives the request that the determination be made;
and
(2) in the case of a life-threatening condition, not later
than the earlier of:
(A) the fifth day after the date the independent review
organization receives the information necessary to make the
determination; or
(B) the eighth day after the date the independent review
organization receives the request that the determination be made.
(d) To be certified as an independent review organization
under this article, an organization must submit to the commissioner
an application in the form required by the commissioner. The
application must include:
(1) for an applicant that is publicly held, the name of each
stockholder or owner of more than five percent of any stock or
options;
(2) the name of any holder of bonds or notes of the applicant
that exceed $100,000;
(3) the name and type of business of each corporation or
other organization that the applicant controls or is affiliated
with and the nature and extent of the affiliation or control;
(4) the name and a biographical sketch of each director,
officer, and executive of the applicant and any entity listed under
Subdivision (3) of this subsection and a description of any
relationship the named individual has with:
(A) a health benefit plan;
(B) a health maintenance organization;
(C) an insurer;
(D) a utilization review agent;
(E) a nonprofit health corporation;
(F) a payor;
(G) a health care provider; or
(H) a group representing any of the entities described by
Paragraphs (A) through (G) of this subdivision;
(5) the percentage of the applicant's revenues that are
anticipated to be derived from reviews conducted under Section 6A,
Article 21.58A of this code;
(6) a description of the areas of expertise of the health
care professionals making review determinations for the applicant;
and
(7) the procedures to be used by the independent review
organization in making review determinations with respect to
reviews conducted under Section 6A, Article 21.58A of this code.
(e) The independent review organization shall annually
submit the information required by Subsection (d) of this section.
If at any time there is a material change in the information
included in the application under Subsection (d) of this section,
the independent review organization shall submit updated
information to the commissioner.
(f) An independent review organization may not be a
subsidiary of, or in any way owned or controlled by, a payor or a
trade or professional association of payors.
(g) An independent review organization conducting a review
under Section 6A, Article 21.58A of this code is not liable for
damages arising from the determination made by the organization.
This subsection does not apply to an act or omission of the
independent review organization that is made in bad faith or that
involves gross negligence.
(h) Information that reveals the identity of a physician or
individual health care provider who makes a review determination
for an independent review organization is confidential.
Added by Acts 1997, 75th Leg., ch. 163, Sec. 8, eff. Sept. 1, 1997.
Sec. 2(h) added by Acts 2003, 78th Leg., ch. 727, Sec. 1, eff. June
20, 2003.
Article: 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 21.79E 21.79H
Last modified: August 11, 2007
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