SUBCHAPTER A GENERAL PROVISIONS
- Texas Section 4201.001 - Purpose
The purpose of this chapter is to: (1) promote the delivery of quality health care in a cost-effective manner; (2) ensure that a utilization review...
- Texas Section 4201.002 - Definitions
In this chapter: (1) "Adverse determination" means a determination by a utilization review agent that health care services provided or proposed to be provided to...
- Texas Section 4201.003 - Rules
(a) The commissioner may adopt rules to implement this chapter. (b) A rule adopted under this chapter relates only to a person or entity subject...
SUBCHAPTER B APPLICABILITY OF CHAPTER
- Texas Section 4201.004 - Telephone Access
(a) A utilization review agent shall: (1) have appropriate personnel reasonably available, by toll-free telephone at least 40 hours per week during normal business hours...
- Texas Section 4201.051 - Persons Providing Information About Scope Of Coverage Or Benefits
This chapter does not apply to a person who: (1) provides information to an enrollee about scope of coverage or benefits provided under a health...
- Texas Section 4201.052 - Certain Contracts With Federal Government
This chapter does not apply to a contract with the federal government to provide utilization review with respect to a patient who is eligible for...
- Texas Section 4201.053 - Medicaid And Other State Health Or Mental Health Programs
(a) Except as provided by Section 4201.057, this chapter does not apply to: (1) the state Medicaid program; (2) the services program for children with...
- Texas Section 4201.054 - Workers' Compensation Benefits
(a) Except as provided by this section, this chapter applies to utilization review of a health care service provided to a person eligible for workers'...
- Texas Section 4201.055 - Health Care Service Provided Under Automobile Insurance Policy
This chapter does not apply to utilization review of a health care service provided under an automobile insurance policy or contract that is authorized under...
- Texas Section 4201.056 - Employee Welfare Benefit Plans
This chapter does not apply to the terms or benefits of an employee welfare benefit plan defined by Section 3(1) of the Employee Retirement Income...
- Texas Section 4201.057 - Health Maintenance Organizations
(a) In this section, "health maintenance organization" includes a health maintenance organization that contracts with the Health and Human Services Commission or with an agency...
SUBCHAPTER C CERTIFICATION
- Texas Section 4201.058 - Insurers
(a) This chapter applies to an insurer subject to this code that delivers or issues for delivery a health insurance policy in this state except...
- Texas Section 4201.101 - Certificate Of Registration Required
A utilization review agent may not conduct utilization review unless the commissioner issues a certificate of registration to the agent under this subchapter. Added by...
- Texas Section 4201.102 - Requirements For Certification
(a) The commissioner may issue a certificate of registration only to an applicant who has met all the requirements of this chapter and all applicable...
- Texas Section 4201.103 - Certificate Renewal
Certification may be renewed biennially by filing, not later than March 1, a renewal form with the commissioner accompanied by a fee in an amount...
- Texas Section 4201.104 - Certification And Renewal Forms
(a) The commissioner shall promulgate forms to be filed under this subchapter for initial certification and for a renewal certificate of registration. The form for...
- Texas Section 4201.105 - Fees
The commissioner shall establish, administer, and enforce the fees for initial certification and certification renewal in amounts that do not exceed the amounts necessary to...
- Texas Section 4201.106 - Certificate Not Transferable
A certificate of registration is not transferable. Added by Acts 2005, 79th Leg., Ch. 727 (H.B. 2017), Sec. 4, eff. April 1, 2007.
- Texas Section 4201.107 - Reporting Material Changes
A utilization review agent shall report any material change to the information disclosed in a form filed under this subchapter not later than the 30th...
SUBCHAPTER D UTILIZATION REVIEW: GENERAL STANDARDS
- Texas Section 4201.108 - List Of Utilization Review Agents
(a) The commissioner shall maintain and update monthly a list of each utilization review agent to whom a certificate of registration has been issued and...
- Texas Section 4201.151 - Utilization Review Plan
A utilization review agent's utilization review plan, including reconsideration and appeal requirements, must be reviewed by a physician and conducted in accordance with standards developed...
- Texas Section 4201.152 - Utilization Review Under Direction Of Physician
A utilization review agent shall conduct utilization review under the direction of a physician licensed to practice medicine by a state licensing agency in the...
- Texas Section 4201.153 - Screening Criteria And Review Procedures
(a) A utilization review agent shall use written medically acceptable screening criteria and review procedures that are established and periodically evaluated and updated with appropriate...
- Texas Section 4201.154 - Review And Inspection Of Screening Criteria And Review Procedures
(a) A utilization review agent's written screening criteria and review procedures shall be made available for: (1) review and inspection to determine appropriateness and compliance...
SUBCHAPTER E UTILIZATION REVIEW: RELATIONS WITH PATIENTS AND HEALTH CARE PROVIDERS
- Texas Section 4201.155 - Limitation On Notice Requirements And Review Procedures
A utilization review agent may not establish or impose a notice requirement or other review procedure that is contrary to the requirements of the health...
- Texas Section 4201.201 - Repetitive Contacts With Health Care Provider Or Patient; Frequency Of Reviews
A utilization review agent: (1) may not engage in unnecessary or unreasonable repetitive contacts with a health care provider or patient; and (2) shall base...
- Texas Section 4201.202 - Observing Or Participating In Patient's Care
(a) Unless approved for an individual patient by the provider of record or modified by contract, a utilization review agent shall be prohibited from observing,...
- Texas Section 4201.203 - Mental Health Therapy
(a) A utilization review agent may not require, as a condition of treatment approval or for any other reason, the observation of a psychotherapy session...
- Texas Section 4201.204 - Complaint System
(a) A utilization review agent shall establish and maintain a complaint system that provides reasonable procedures for the resolution of oral or written complaints initiated...
- Texas Section 4201.205 - Designated Initial Contact
(a) A health care provider may designate one or more individuals as the initial contact or contacts for a utilization review agent seeking routine information...
- Texas Section 4201.206 - Opportunity To Discuss Treatment Before Adverse Determination
Subject to the notice requirements of Subchapter G, before an adverse determination is issued by a utilization review agent who questions the medical necessity or...
SUBCHAPTER F UTILIZATION REVIEW: PERSONNEL
- Texas Section 4201.207 - Charges By Health Care Provider For Providing Medical Information
(a) Unless precluded or modified by contract, a utilization review agent shall reimburse a health care provider for the reasonable costs of providing medical information...
- Texas Section 4201.251 - Delegation Of Utilization Review
A utilization review agent may delegate utilization review to qualified personnel in the hospital or other health care facility in which the health care services...
- Texas Section 4201.252 - Personnel
(a) Personnel employed by or under contract with a utilization review agent to perform utilization review must be appropriately trained and qualified. (b) Personnel, other...
SUBCHAPTER G NOTICE OF DETERMINATIONS
- Texas Section 4201.253 - Prohibited Bases For Employment, Compensation, Evaluations, Or Performance Standards
A utilization review agent may not permit or provide compensation or another thing of value to an employee or agent of the utilization review agent,...
- Texas Section 4201.301 - General Duty To Notify
A utilization review agent shall provide notice of a determination made in a utilization review to: (1) the enrollee's provider of record; and (2) the...
- Texas Section 4201.302 - General Time For Notice
A utilization review agent must mail or otherwise transmit the notice required by this subchapter not later than the second working day after the date...
- Texas Section 4201.303 - Adverse Determination: Contents Of Notice
(a) Notice of an adverse determination must include: (1) the principal reasons for the adverse determination; (2) the clinical basis for the adverse determination; (3)...
- Texas Section 4201.304 - Time For Notice Of Adverse Determination
(a) Subject to Subsection (b), a utilization review agent shall provide notice of an adverse determination required by this subchapter as follows: (1) with respect...
SUBCHAPTER H APPEAL OF ADVERSE DETERMINATION
- Texas Section 4201.305 - Notice Of Adverse Determination For Retrospective Utilization Review
(a) Notwithstanding Sections 4201.302 and 4201.304, if a retrospective utilization review is conducted, the utilization review agent shall provide notice of an adverse determination under...
- Texas Section 4201.351 - Complaint As Appeal
For purposes of this subchapter, a complaint filed concerning dissatisfaction or disagreement with an adverse determination constitutes an appeal of that adverse determination. Added by...
- Texas Section 4201.352 - Written Description Of Appeal Procedures
A utilization review agent shall maintain and make available a written description of the procedures for appealing an adverse determination. Added by Acts 2005, 79th...
- Texas Section 4201.353 - Appeal Procedures Must Be Reasonable
The procedures for appealing an adverse determination must be reasonable. Added by Acts 2005, 79th Leg., Ch. 727 (H.B. 2017), Sec. 4, eff. April 1,
- Texas Section 4201.354 - Persons Or Entities Who May Appeal
The procedures for appealing an adverse determination must provide that the adverse determination may be appealed orally or in writing by: (1) an enrollee; (2)...
- Texas Section 4201.355 - Acknowledgment Of Appeal
(a) The procedures for appealing an adverse determination must provide that, within five working days from the date the utilization review agent receives the appeal,...
- Texas Section 4201.356 - Decision By Physician Required; Specialty Review
(a) The procedures for appealing an adverse determination must provide that a physician makes the decision on the appeal, except as provided by Subsection (b)....
- Texas Section 4201.357 - Expedited Appeal For Denial Of Emergency Care, Continued Hospitalization, Prescription Drugs Or Intravenous Infusions
(a) The procedures for appealing an adverse determination must include, in addition to the written appeal, a procedure for an expedited appeal of a denial...
- Texas Section 4201.358 - Response Letter To Interested Persons
The procedures for appealing an adverse determination must provide that, after the utilization review agent has sought review of the appeal, the agent shall issue...
- Texas Section 4201.359 - Notice Of Appeal
(a) The procedures for appealing an adverse determination must require written notice to the appealing party of the determination of the appeal as soon as...
- Texas Section 4201.360 - Immediate Appeal To Independent Review Organization In Life-threatening Circumstances
Notwithstanding any other law, in a circumstance involving an enrollee's life-threatening condition, the enrollee is: (1) entitled to an immediate appeal to an independent review...
SUBCHAPTER I INDEPENDENT REVIEW OF ADVERSE DETERMINATION
- Texas Section 4201.3601 - Immediate Appeal To Independent Review Organization For Denial Of Prescription Drugs Or Intravenous Infusions
Notwithstanding any other law, in a circumstance involving the provision of prescription drugs or intravenous infusions for which the patient is receiving benefits under the...
- Texas Section 4201.401 - Review By Independent Review Organization; Compliance With Independent Determination
(a) A utilization review agent shall allow any party whose appeal of an adverse determination is denied by the agent to seek review of that...
- Texas Section 4201.402 - Information Provided To Independent Review Organization
(a) Not later than the third business day after the date a utilization review agent receives a request for independent review, the agent shall provide...
SUBCHAPTER J SPECIALTY UTILIZATION REVIEW AGENTS
- Texas Section 4201.403 - Payment For Independent Review
A utilization review agent shall pay for an independent review conducted under this subchapter. Added by Acts 2005, 79th Leg., Ch. 727 (H.B. 2017), Sec....
- Texas Section 4201.451 - Definition
For purposes of this subchapter, "specialty utilization review agent" means a utilization review agent who conducts utilization review for a specialty health care service, including...
- Texas Section 4201.452 - Inapplicability Of Certain Other Law
A specialty utilization review agent is not subject to Section 4201.151, 4201.152, 4201.206, 4201.252, or 4201.356. Added by Acts 2005, 79th Leg., Ch. 727 (H.B....
- Texas Section 4201.453 - Utilization Review Plan
A specialty utilization review agent's utilization review plan, including reconsideration and appeal requirements, must be reviewed by a health care provider of the appropriate specialty...
- Texas Section 4201.454 - Utilization Review Under Direction Of Provider Of Same Specialty
A specialty utilization review agent shall conduct utilization review under the direction of a health care provider who is of the same specialty as the...
- Texas Section 4201.455 - Personnel
(a) Personnel who are employed by or under contract with a specialty utilization review agent to perform utilization review must be appropriately trained and qualified....
- Texas Section 4201.456 - Opportunity To Discuss Treatment Before Adverse Determination
Subject to the notice requirements of Subchapter G, before an adverse determination is issued by a specialty utilization review agent who questions the medical necessity...
SUBCHAPTER L CONFIDENTIALITY OF INFORMATION; ACCESS TO OTHER INFORMATION
- Texas Section 4201.457 - Appeal Decisions
A specialty utilization review agent shall comply with the requirement that a physician or other health care provider who makes the decision in an appeal...
- Texas Section 4201.551 - General Confidentiality Requirement
(a) A utilization review agent shall preserve the confidentiality of individual medical records to the extent required by law. (b) This chapter does not authorize...
- Texas Section 4201.552 - Consent Requirements
(a) A utilization review agent may not disclose individual medical records, personal information, or other confidential information about a patient obtained in the performance of...
- Texas Section 4201.553 - Providing Information To Affiliated Entities
A utilization review agent may provide confidential information to a third party under contract with or affiliated with the agent solely to perform or assist...
- Texas Section 4201.554 - Providing Information To Commissioner
Notwithstanding this subchapter, a utilization review agent shall provide to the commissioner on request individual medical records or other confidential information to enable the commissioner...
- Texas Section 4201.555 - Access To Recorded Personal Information
(a) If an individual submits a written request to a utilization review agent for access to recorded personal information concerning the individual, the agent shall,...
- Texas Section 4201.556 - Publishing Information Identifiable To Health Care Provider
(a) A utilization review agent may not publish data that identifies a particular physician or other health care provider, including data in a quality review...
- Texas Section 4201.557 - Requirement To Maintain Data In Confidential Manner
A utilization review agent shall maintain all data concerning a patient or physician or other health care provider in a confidential manner that prevents unauthorized...
SUBCHAPTER M ENFORCEMENT
- Texas Section 4201.558 - Destruction Of Certain Confidential Documents
When a utilization review agent determines a document in the custody of the agent that contains confidential patient information or confidential physician or other health...
- Texas Section 4201.601 - Notice Of Suspected Violation; Compelling Production Of Information
If the commissioner believes that a person or entity conducting utilization review is in violation of this chapter or applicable rules, the commissioner: (1) shall...
- Texas Section 4201.602 - Enforcement Proceeding
(a) The commissioner may initiate a proceeding under this subchapter. (b) A proceeding under this chapter is a contested case for purposes of Chapter 2001,...
- Texas Section 4201.603 - Remedies And Penalties For Violation
If the commissioner determines that a utilization review agent, health maintenance organization, insurer, or other person or entity conducting utilization review has violated or is...