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Statutes > Texas > Insurance-code > Title-14-utilization-review-and-independent-review > Chapter-4201-utilization-review-agents

INSURANCE CODE

TITLE 14. UTILIZATION REVIEW AND INDEPENDENT REVIEW

CHAPTER 4201. UTILIZATION REVIEW AGENTS

SUBCHAPTER A. GENERAL PROVISIONS

Sec. 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 agent adheres to reasonable

standards for conducting utilization review;

(3) foster greater coordination and cooperation between a health

care provider and utilization review agent;

(4) improve communications and knowledge of benefits among all

parties concerned before an expense is incurred; and

(5) ensure that a utilization review agent maintains the

confidentiality of medical records in accordance with applicable

law.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 a patient are not medically necessary

or are experimental or investigational.

(2) "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 severe pain, that would lead a prudent layperson

possessing an average knowledge of medicine and health to believe

that the individual's condition, sickness, or injury is of such a

nature that failure to get immediate medical care could:

(A) place the individual's health in serious jeopardy;

(B) result in serious impairment to bodily functions;

(C) result in serious dysfunction of a bodily organ or part;

(D) result in serious disfigurement; or

(E) for a pregnant woman, result in serious jeopardy to the

health of the fetus.

(3) "Enrollee" means an individual covered by a health

insurance policy or health benefit plan. The term includes an

individual who is covered as an eligible dependent of another

individual.

(4) "Health benefit plan" means a plan of benefits, other than a

health insurance policy, that:

(A) defines the coverage provisions for health care for

enrollees; and

(B) is offered or provided by a public or private organization.

(5) "Health care provider" means a person, corporation,

facility, or institution that is:

(A) licensed by a state to provide or is otherwise lawfully

providing health care services; and

(B) eligible for independent reimbursement for those health care

services.

(6) "Health insurance policy" means an insurance policy,

including a policy written by a corporation subject to Chapter

842, that provides coverage for medical or surgical expenses

incurred as a result of accident or sickness.

(7) "Life-threatening" means a disease or condition from which

the likelihood of death is probable unless the course of the

disease or condition is interrupted.

(8) "Nurse" means a professional or registered nurse, a licensed

vocational nurse, or a licensed practical nurse.

(9) "Patient" means the enrollee or an eligible dependent of the

enrollee under a health benefit plan or health insurance policy.

(10) "Payor" means:

(A) an insurer that writes health insurance policies;

(B) a preferred provider organization, health maintenance

organization, or self-insurance plan; or

(C) any other person or entity that provides, offers to provide,

or administers hospital, outpatient, medical, or other health

benefits to a person treated by a health care provider in this

state under a policy, plan, or contract.

(11) "Physician" means a licensed doctor of medicine or a doctor

of osteopathy.

(12) "Provider of record" means the physician or other health

care provider with primary responsibility for the care,

treatment, and services provided to an enrollee. The term

includes a health care facility if treatment is provided on an

inpatient or outpatient basis.

(13) "Utilization review" includes a system for prospective,

concurrent, or retrospective review of the medical necessity and

appropriateness of health care services and a system for

prospective, concurrent, or retrospective review to determine the

experimental or investigational nature of health care services.

The term does not include a review in response to an elective

request for clarification of coverage.

(14) "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 holding a certificate of authority under

Chapter 4151.

(15) "Utilization review plan" means the screening criteria and

utilization review procedures of a utilization review agent.

(16) "Working day" means a weekday that is not a legal holiday.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Amended by:

Acts 2009, 81st Leg., R.S., Ch.

1330, Sec. 7, eff. September 1, 2009.

Sec. 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 to this chapter.

(c) The commissioner shall appoint an advisory committee to

advise the commissioner on development of rules regarding the

administration of this chapter, as authorized by Section

2001.031, Government Code. The committee includes:

(1) the public counsel appointed under Chapter 501; and

(2) one representative for each of the following:

(A) insurers;

(B) health maintenance organizations;

(C) group hospital service corporations;

(D) utilization review agents;

(E) employers;

(F) consumer organizations;

(G) physicians;

(H) dentists;

(I) hospitals;

(J) registered nurses; and

(K) other health care providers.

(d) The advisory committee's deliberations are subject to

Chapter 551, Government Code.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 in this state, to discuss patients' care and allow

response to telephone review requests;

(2) have a telephone system capable, during hours other than

normal business hours, of accepting or recording incoming

telephone calls or of providing instructions to a caller; and

(3) respond to a call made during hours other than normal

business hours not later than the second working day after the

later of:

(A) the date the call was received; or

(B) the date the details necessary to respond have been received

from the caller.

(b) A utilization review agent must provide to the commissioner

a written description of the procedures to be used when

responding with respect to poststabilization care subsequent to

emergency treatment as requested by a treating physician or other

health care provider.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

SUBCHAPTER B. APPLICABILITY OF CHAPTER

Sec. 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 insurance policy or health

benefit plan; and

(2) does not determine whether a particular health care service

provided or to be provided to an enrollee is:

(A) medically necessary or appropriate; or

(B) experimental or investigational.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Amended by:

Acts 2009, 81st Leg., R.S., Ch.

1330, Sec. 8, eff. September 1, 2009.

Sec. 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 services under Title XVIII or XIX of the Social

Security Act (42 U.S.C. Section 1395 et seq. or Section 1396 et

seq.).

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 4201.053. MEDICAID AND CERTAIN OTHER STATE HEALTH OR MENTAL

HEALTH PROGRAMS. 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 special health care

needs under Chapter 35, Health and Safety Code;

(3) a program administered under Title 2, Human Resources Code;

(4) a program of the Department of State Health Services

relating to mental health services;

(5) a program of the Department of Aging and Disability Services

relating to mental retardation services; or

(6) a program of the Texas Department of Criminal Justice.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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' compensation medical benefits under Title 5, Labor Code.

The commissioner of workers' compensation shall regulate as

provided by this chapter a person who performs utilization review

of a medical benefit provided under Title 5, Labor Code.

(b) Repealed by Acts 2007, 80th Leg., R.S., Ch. 730, Sec.

3B.075(b), eff. September 1, 2007.

(c) Title 5, Labor Code, prevails in the event of a conflict

between this chapter and Title 5, Labor Code.

(d) The commissioner of workers' compensation may adopt rules as

necessary to implement this section.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Amended by:

Acts 2007, 80th Leg., R.S., Ch.

134, Sec. 7(a), eff. September 1, 2007.

Acts 2007, 80th Leg., R.S., Ch.

134, Sec. 7(b), eff. September 1, 2007.

Acts 2007, 80th Leg., R.S., Ch.

730, Sec. 3B.075(a), eff. September 1, 2007.

Acts 2007, 80th Leg., R.S., Ch.

730, Sec. 3B.075(b), eff. September 1, 2007.

Acts 2007, 80th Leg., R.S., Ch.

921, Sec. 9.075(a), eff. September 1, 2007.

Acts 2007, 80th Leg., R.S., Ch.

921, Sec. 9.075(b), eff. September 1, 2007.

Sec. 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 Chapter

2301 or Article 5.13-2 or that is issued under Chapter 981.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 Security Act of 1974 (29 U.S.C. Section 1002(1)).

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 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.

(b) This chapter applies to a health maintenance organization

except as expressly provided by this section.

(c) As a condition of holding a certificate of authority to

engage in the business of a health maintenance organization, a

health maintenance organization that performs utilization review

must:

(1) comply with this chapter, except Subchapter C; and

(2) submit to assessment of a maintenance tax under Chapter 258

to cover the costs of administering compliance with this

subsection.

(d) The commissioner shall adopt rules for appropriate

verification and enforcement of compliance with Subsection (c).

(e) Notwithstanding Subsection (c)(1), a health maintenance

organization that performs utilization review for a person or

entity subject to this chapter, other than a person or entity for

which the health maintenance organization is the payor, must

obtain a certificate of registration under Subchapter C and shall

comply with all of the provisions of this chapter.

(f) This chapter does not prohibit or limit the distribution of

a portion 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 withholding arrangements to a participating

physician or participating health care provider for providing

health care services to an enrollee.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 as expressly

provided by this section. As a condition of holding a

certificate of authority to engage in the business of insurance,

an insurer that performs utilization review shall comply with

this chapter, except Subchapter C. The insurer is subject to

assessment of a maintenance tax under Chapter 257 to cover the

costs of administering compliance with this subsection.

(b) The commissioner shall adopt rules for appropriate

verification and enforcement of compliance with Subsection (a).

(c) Notwithstanding Subsection (a), an insurer subject to this

code that performs utilization review for a person or entity

subject to this chapter, other than a person or entity for which

the insurer is the payor, must obtain a certificate of

registration under Subchapter C and shall comply with all of the

provisions of this chapter.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

SUBCHAPTER C. CERTIFICATION

Sec. 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 Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 rules adopted by the commissioner.

(b) As a condition of holding a certificate of registration or

renewal of a certificate, a utilization review agent must

maintain compliance with Subchapters D, E, and F.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 set

by the commissioner.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 initial certification

must require:

(1) the utilization review agent'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;

(4) information concerning the categories of personnel who will

perform utilization review for the agent;

(5) a copy of the procedures established under Subchapter H for

the appeal of an adverse determination;

(6) a certification that the agent will comply with this

chapter; and

(7) a copy of the procedures for resolving oral or written

complaints initiated by enrollees, patients, or health care

providers as required by Section 4201.204.

(b) The commissioner may not require that the summary of the

utilization review plan include proprietary details.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 cover the cost of administering this chapter.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 4201.106. CERTIFICATE NOT TRANSFERABLE. A certificate of

registration is not transferable.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 day after the date the change takes effect.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 the renewal date of the certificate.

(b) The commissioner shall provide the list at cost to each

individual or organization requesting the list.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

SUBCHAPTER D. UTILIZATION REVIEW: GENERAL STANDARDS

Sec. 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 with input from

appropriate health care providers and approved by a physician.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 United States.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 involvement

from physicians, including practicing physicians, dentists, and

other health care providers.

(b) A utilization review determination shall be made in

accordance with currently accepted medical or health care

practices, taking into account special circumstances of the case

that may require deviation from the norm stated in the screening

criteria.

(c) Screening criteria must be:

(1) objective;

(2) clinically valid;

(3) compatible with established principles of health care; and

(4) flexible enough to allow a deviation from the norm when

justified on a case-by-case basis.

(d) Screening criteria must be used to determine only whether to

approve the requested treatment. A denial of requested treatment

must be referred to an appropriate physician, dentist, or other

health care provider to determine medical necessity.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 as considered necessary by the commissioner; and

(2) copying as necessary for the commissioner to accomplish the

commissioner's duties under this code.

(b) Any information obtained or acquired under the authority of

this section, Section 4201.153, and this chapter is confidential

and privileged and is not subject to Chapter 552, Government

Code, or to subpoena except to the extent necessary for the

commissioner to enforce this chapter.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 insurance policy or

health benefit plan.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

SUBCHAPTER E. UTILIZATION REVIEW: RELATIONS WITH PATIENTS AND

HEALTH CARE PROVIDERS

Sec. 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 the frequency of contacts or reviews on the

severity or complexity of the patient's condition or on necessary

treatment and discharge planning activity.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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, participating in, or otherwise

being present during a patient's examination, treatment,

procedure, or therapy.

(b) This subchapter, Subchapters D and F, and Section

4201.102(b) may not be construed to otherwise limit or deny

contact with a patient for purposes of conducting utilization

review unless otherwise specifically prohibited by law.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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

or the submission or review of a mental health therapist's

process or progress notes.

(b) Notwithstanding this section, a utilization review agent may

require submission of a patient's medical record summary.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 by enrollees, patients, or health

care providers concerning the utilization review.

(b) The complaint procedure must include a requirement that the

utilization review agent provide a written response to the

complainant within 30 days.

(c) A utilization review agent shall submit to the commissioner

a summary report of all complaints at the times and in the form

specified by the commissioner. The agent shall allow the

commissioner to examine the complaints and relevant documents at

any time.

(d) A utilization review agent shall maintain a record of each

complaint until the third anniversary of the date the complainant

filed the complaint.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 or data.

(b) A designation made under this section may not preclude a

utilization review agent or medical advisor from contacting a

health care provider or the provider's employees who are not

designated under this section under circumstances in which:

(1) a review might otherwise be unreasonably delayed; or

(2) the designated individual is unable to provide the necessary

data or information that the agent requests.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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

appropriateness, or the experimental or investigational nature,

of a health care service, the agent shall provide the health care

provider who ordered the service a reasonable opportunity to

discuss with a physician the patient's treatment plan and the

clinical basis for the agent's determination.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Amended by:

Acts 2009, 81st Leg., R.S., Ch.

1330, Sec. 9, eff. September 1, 2009.

Sec. 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 in writing, including the costs of copying and

transmitting requested patient records or other documents.

(b) A health care provider's charges for providing medical

information to a utilization review agent may not:

(1) exceed the cost of copying records regarding a workers'

compensation claim as set by rules adopted by the commissioner of

workers' compensation; or

(2) include any costs otherwise recouped as part of the charges

for health care.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Amended by:

Acts 2007, 80th Leg., R.S., Ch.

134, Sec. 8(a), eff. September 1, 2007.

Acts 2007, 80th Leg., R.S., Ch.

730, Sec. 3B.076(a), eff. September 1, 2007.

Acts 2007, 80th Leg., R.S., Ch.

921, Sec. 9.076(a), eff. September 1, 2007.

SUBCHAPTER F. UTILIZATION REVIEW: PERSONNEL

Sec. 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 to be reviewed were or are to be

provided. The delegation does not release the agent from the

full responsibility for compliance with this chapter, including

the conduct of those to whom utilization review has been

delegated.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 than a physician, who obtain oral or

written information directly from a patient's physician or other

health care provider regarding the patient's specific medical

condition, diagnosis, or treatment options or protocols must be a

nurse, physician assistant, or other health care provider

qualified to provide the requested service.

(c) This section may not be interpreted to require personnel who

perform clerical or administrative tasks to have the

qualifications prescribed by this section.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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,

condition employment of the agent's employees or agent

evaluations, or set employee or agent performance standards,

based on the amount of volume of adverse determinations,

reductions of or limitations on lengths of stay, benefits,

services, or charges, or the number or frequency of telephone

calls or other contacts with health care providers or patients,

that are inconsistent with this chapter.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

SUBCHAPTER G. NOTICE OF DETERMINATIONS

Sec. 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 enrollee or a person acting on the enrollee's behalf.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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

of the request for utilization review and the agent receives all

information necessary to complete the review.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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) a description of or the source of the screening criteria

used as guidelines in making the adverse determination; and

(4) a description of the procedure for the complaint and appeal

process, including notice to the enrollee of the enrollee's right

to appeal an adverse determination to an independent review

organization and of the procedures to obtain that review.

(b) For an enrollee who has a life-threatening condition, the

notice required by Subsection (a)(4) must include a description

of the enrollee's right to an immediate review by an independent

review organization and of the procedures to obtain that review.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 4201.304. TIME FOR NOTICE OF ADVERSE DETERMINATION. A

utilization review agent shall provide notice of an adverse

determination required by this subchapter as follows:

(1) with respect to a patient who is hospitalized at the time of

the adverse determination, within one working day by either

telephone or electronic transmission to the provider of record,

followed by a letter within three working days notifying the

patient and the provider of record of the adverse determination;

(2) with respect to a patient who is not hospitalized at the

time of the adverse determination, within three working days in

writing to the provider of record and the patient; or

(3) within the time appropriate to the circumstances relating to

the delivery of the services to the patient and to the patient's

condition, provided that when denying poststabilization care

subsequent to emergency treatment as requested by a treating

physician or other health care provider, the agent shall provide

the notice to the treating physician or other health care

provider not later than one hour after the time of the request.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 the retrospective utilization review in

writing to the provider of record and the patient within a

reasonable period, but not later than 30 days after the date on

which the claim is received.

(b) The period under Subsection (a) may be extended once by the

utilization review agent for a period not to exceed 15 days, if

the utilization review agent:

(1) determines that an extension is necessary due to matters

beyond the utilization review agent's control; and

(2) notifies the provider of record and the patient before the

expiration of the initial 30-day period of the circumstances

requiring the extension and the date by which the utilization

review agent expects to make a determination.

(c) If the extension under Subsection (b) is required because of

the failure of the provider of record or the patient to submit

information necessary to reach a determination on the request,

the notice of extension must:

(1) specifically describe the required information necessary to

complete the request; and

(2) give the provider of record and the patient at least 45 days

from the date of receipt of the notice of extension to provide

the specified information.

(d) If the period for making the determination under this

section is extended because of the failure of the provider of

record or the patient to submit the information necessary to make

the determination, the period for making the determination is

tolled from the date on which the utilization review agent sends

the notification of the extension to the provider of record or

the patient until the earlier of:

(1) the date on which the provider of record or the patient

responds to the request for additional information; or

(2) the date by which the specified information was to have been

submitted.

(e) If the periods for retrospective utilization review provided

by this section conflict with the time limits concerning or

related to payment of claims established under Subchapter J,

Chapter 843, the time limits established under Subchapter J,

Chapter 843, control.

(f) If the periods for retrospective utilization review provided

by this section conflict with the time limits concerning or

related to payment of claims established under Subchapters C and

C-1, Chapter 1301, the time limits established under Subchapters

C and C-1, Chapter 1301, control.

(g) If the periods for retrospective utilization review provided

by this section conflict with the time limits concerning or

related to payment of claims established under Section 408.027,

Labor Code, the time limits established under Section 408.027,

Labor Code, control.

Added by Acts 2009, 81st Leg., R.S., Ch.

1330, Sec. 10, eff. September 1, 2009.

SUBCHAPTER H. APPEAL OF ADVERSE DETERMINATION

Sec. 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 Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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, Sec. 4, eff. April 1, 2007.

Sec. 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) a person acting on the enrollee's behalf; or

(3) the enrollee's physician or other health care provider.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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, the agent shall send to the appealing party

a letter acknowledging the date of receipt.

(b) The letter must also include a list of:

(1) the procedures required by this subchapter; and

(2) the documents that the appealing party must submit for

review.

(c) When a utilization review agent receives an oral appeal of

an adverse determination, the agent shall send a one-page appeal

form to the appealing party.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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).

(b) If not later than the 10th working day after the date an

appeal is denied the enrollee's health care provider states in

writing good cause for having a particular type of specialty

provider review the case, a health care provider who is of the

same or a similar specialty as the health care provider who would

typically manage the medical or dental condition, procedure, or

treatment under consideration for review shall review the

decision denying the appeal. The specialty review must be

completed within 15 working days of the date the health care

provider's request for specialty review is received.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 4201.357. EXPEDITED APPEAL FOR DENIAL OF EMERGENCY CARE OR

CONTINUED HOSPITALIZATION. (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 of

emergency care or a denial of continued hospitalization. That

procedure must include a review by a health care provider who:

(1) has not previously reviewed the case; and

(2) is of the same or a similar specialty as the health care

provider who would typically manage the medical or dental

condition, procedure, or treatment under review in the appeal.

(b) The time for resolution of an expedited appeal under this

section shall be based on the medical or dental immediacy of the

condition, procedure, or treatment under review, provided that

the resolution of the appeal may not exceed one working day from

the date all information necessary to complete the appeal is

received.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 a response letter explaining the

resolution of the appeal to:

(1) the patient or a person acting on the patient's behalf; and

(2) the patient's physician or other health care provider.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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

practicable, but not later than the 30th calendar day, after the

date the utilization review agent receives the appeal.

(b) If the appeal is denied, the notice must include a clear and

concise statement of:

(1) the clinical basis for the denial;

(2) the specialty of the physician or other health care provider

making the denial; and

(3) the appealing party's right to seek review of the denial by

an independent review organization under Subchapter I and the

procedures for obtaining that review.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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

organization as provided by Subchapter I; and

(2) not required to comply with procedures for an internal

review of the utilization review agent's adverse determination.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

SUBCHAPTER I. INDEPENDENT REVIEW OF ADVERSE DETERMINATION

Sec. 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

determination by an independent review organization assigned to

the appeal in accordance with Chapter 4202.

(b) The utilization review agent shall comply with the

independent review organization's determination regarding the

medical necessity or appropriateness of health care items and

services for an enrollee.

(c) The utilization review agent shall comply with the

independent review organization's determination regarding the

experimental or investigational nature of health care items and

services for an enrollee.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Amended by:

Acts 2009, 81st Leg., R.S., Ch.

1330, Sec. 11, eff. September 1, 2009.

Sec. 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 to the appropriate

independent review organization:

(1) 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;

(C) the written notification described by Section 4201.359; and

(D) any documents and other written information submitted to the

agent in support of the appeal; and

(2) a list of each physician or other health care provider who:

(A) has provided care to the enrollee; and

(B) may have medical records relevant to the appeal.

(b) A utilization review agent may provide confidential

information in the custody of the agent to an independent review

organization, subject to rules and standards adopted by the

commissioner under Chapter 4202.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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, Sec. 4, eff. April 1, 2007.

SUBCHAPTER J. SPECIALTY UTILIZATION REVIEW AGENTS

Sec. 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 dentistry, chiropractic services, or physical

therapy.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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, Sec. 4, eff. April 1, 2007.

Sec. 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 and conducted in accordance

with standards developed with input from a health care provider

of the appropriate specialty.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 agent and who is

licensed or otherwise authorized to provide the specialty health

care service by a state licensing agency in the United States.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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.

(b) Personnel who obtain oral or written information directly

from a physician or other health care provider must be a nurse,

physician assistant, or other health care provider of the same

specialty as the agent and who are licensed or otherwise

authorized to provide the specialty health care service by a

state licensing agency in the United States.

(c) This section does not require personnel who perform only

clerical or administrative tasks to have the qualifications

prescribed by this section.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 or

appropriateness, or the experimental or investigational nature,

of a health care service, the agent shall provide the health care

provider who ordered the service a reasonable opportunity to

discuss the patient's treatment plan and the clinical basis for

the agent's determination with a health care provider who is of

the same specialty as the agent.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Amended by:

Acts 2009, 81st Leg., R.S., Ch.

1330, Sec. 12, eff. September 1, 2009.

Sec. 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 of an

adverse determination must be of the same or a similar specialty

as the health care provider who would typically manage the

specialty condition, procedure, or treatment under review in the

appeal.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

SUBCHAPTER L. CONFIDENTIALITY OF INFORMATION; ACCESS TO OTHER

INFORMATION

Sec. 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 a utilization review agent

to take any action that violates a state or federal law or

regulation concerning confidentiality of patient records.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 utilization review without the

patient's prior written consent or except as otherwise required

by law.

(b) If the prior written consent is submitted by anyone other

than the patient who is the subject of the personal or

confidential information requested, the consent must:

(1) be dated; and

(2) contain the patient's signature.

(c) The patient's signature for purposes of Subsection (b)(2)

must have been obtained one year or less before the date the

disclosure is sought or the consent is invalid.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 with utilization review. Information

provided to a third party under this section remains

confidential.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 to

determine compliance with this chapter. The information is

confidential and privileged and is not subject to Chapter 552,

Government Code, or to subpoena, except to the extent necessary

to enable the commissioner to enforce this chapter.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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, within 10 business days from the

date the agent receives the request:

(1) inform the requesting individual in writing of the nature

and substance of the recorded personal information; and

(2) allow the individual, at the individual's discretion, to:

(A) view and copy, in person, the recorded personal information

concerning the individual; or

(B) obtain a copy of the information by mail.

(b) If the information requested under this section is in coded

form, the utilization review agent shall provide in writing an

accurate translation of the information in plain language.

(c) A utilization review agent's charges for providing a copy of

information requested under this section shall be reasonable, as

determined by rule adopted by the commissioner. The charges may

not include any costs otherwise recouped as part of the charges

for utilization review.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 study or performance

tracking data, without providing prior written notice to the

physician or other provider.

(b) The prohibition under this section does not apply to

internal systems or reports used by the utilization review agent.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 disclosure to

a third party.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 care

provider financial data is no longer needed, the document shall

be destroyed by a method that ensures the complete destruction of

the information.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

SUBCHAPTER M. ENFORCEMENT

Sec. 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 notify the utilization review agent, health

maintenance organization, or insurer of the alleged violation;

and

(2) may compel the production of documents or other information

as necessary to determine whether a violation has occurred.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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, Government Code.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 violating this

chapter, the commissioner may:

(1) impose a sanction under Chapter 82;

(2) issue a cease and desist order under Chapter 83; or

(3) assess an administrative penalty under Chapter 84.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

State Codes and Statutes

Statutes > Texas > Insurance-code > Title-14-utilization-review-and-independent-review > Chapter-4201-utilization-review-agents

INSURANCE CODE

TITLE 14. UTILIZATION REVIEW AND INDEPENDENT REVIEW

CHAPTER 4201. UTILIZATION REVIEW AGENTS

SUBCHAPTER A. GENERAL PROVISIONS

Sec. 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 agent adheres to reasonable

standards for conducting utilization review;

(3) foster greater coordination and cooperation between a health

care provider and utilization review agent;

(4) improve communications and knowledge of benefits among all

parties concerned before an expense is incurred; and

(5) ensure that a utilization review agent maintains the

confidentiality of medical records in accordance with applicable

law.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 a patient are not medically necessary

or are experimental or investigational.

(2) "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 severe pain, that would lead a prudent layperson

possessing an average knowledge of medicine and health to believe

that the individual's condition, sickness, or injury is of such a

nature that failure to get immediate medical care could:

(A) place the individual's health in serious jeopardy;

(B) result in serious impairment to bodily functions;

(C) result in serious dysfunction of a bodily organ or part;

(D) result in serious disfigurement; or

(E) for a pregnant woman, result in serious jeopardy to the

health of the fetus.

(3) "Enrollee" means an individual covered by a health

insurance policy or health benefit plan. The term includes an

individual who is covered as an eligible dependent of another

individual.

(4) "Health benefit plan" means a plan of benefits, other than a

health insurance policy, that:

(A) defines the coverage provisions for health care for

enrollees; and

(B) is offered or provided by a public or private organization.

(5) "Health care provider" means a person, corporation,

facility, or institution that is:

(A) licensed by a state to provide or is otherwise lawfully

providing health care services; and

(B) eligible for independent reimbursement for those health care

services.

(6) "Health insurance policy" means an insurance policy,

including a policy written by a corporation subject to Chapter

842, that provides coverage for medical or surgical expenses

incurred as a result of accident or sickness.

(7) "Life-threatening" means a disease or condition from which

the likelihood of death is probable unless the course of the

disease or condition is interrupted.

(8) "Nurse" means a professional or registered nurse, a licensed

vocational nurse, or a licensed practical nurse.

(9) "Patient" means the enrollee or an eligible dependent of the

enrollee under a health benefit plan or health insurance policy.

(10) "Payor" means:

(A) an insurer that writes health insurance policies;

(B) a preferred provider organization, health maintenance

organization, or self-insurance plan; or

(C) any other person or entity that provides, offers to provide,

or administers hospital, outpatient, medical, or other health

benefits to a person treated by a health care provider in this

state under a policy, plan, or contract.

(11) "Physician" means a licensed doctor of medicine or a doctor

of osteopathy.

(12) "Provider of record" means the physician or other health

care provider with primary responsibility for the care,

treatment, and services provided to an enrollee. The term

includes a health care facility if treatment is provided on an

inpatient or outpatient basis.

(13) "Utilization review" includes a system for prospective,

concurrent, or retrospective review of the medical necessity and

appropriateness of health care services and a system for

prospective, concurrent, or retrospective review to determine the

experimental or investigational nature of health care services.

The term does not include a review in response to an elective

request for clarification of coverage.

(14) "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 holding a certificate of authority under

Chapter 4151.

(15) "Utilization review plan" means the screening criteria and

utilization review procedures of a utilization review agent.

(16) "Working day" means a weekday that is not a legal holiday.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Amended by:

Acts 2009, 81st Leg., R.S., Ch.

1330, Sec. 7, eff. September 1, 2009.

Sec. 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 to this chapter.

(c) The commissioner shall appoint an advisory committee to

advise the commissioner on development of rules regarding the

administration of this chapter, as authorized by Section

2001.031, Government Code. The committee includes:

(1) the public counsel appointed under Chapter 501; and

(2) one representative for each of the following:

(A) insurers;

(B) health maintenance organizations;

(C) group hospital service corporations;

(D) utilization review agents;

(E) employers;

(F) consumer organizations;

(G) physicians;

(H) dentists;

(I) hospitals;

(J) registered nurses; and

(K) other health care providers.

(d) The advisory committee's deliberations are subject to

Chapter 551, Government Code.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 in this state, to discuss patients' care and allow

response to telephone review requests;

(2) have a telephone system capable, during hours other than

normal business hours, of accepting or recording incoming

telephone calls or of providing instructions to a caller; and

(3) respond to a call made during hours other than normal

business hours not later than the second working day after the

later of:

(A) the date the call was received; or

(B) the date the details necessary to respond have been received

from the caller.

(b) A utilization review agent must provide to the commissioner

a written description of the procedures to be used when

responding with respect to poststabilization care subsequent to

emergency treatment as requested by a treating physician or other

health care provider.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

SUBCHAPTER B. APPLICABILITY OF CHAPTER

Sec. 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 insurance policy or health

benefit plan; and

(2) does not determine whether a particular health care service

provided or to be provided to an enrollee is:

(A) medically necessary or appropriate; or

(B) experimental or investigational.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Amended by:

Acts 2009, 81st Leg., R.S., Ch.

1330, Sec. 8, eff. September 1, 2009.

Sec. 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 services under Title XVIII or XIX of the Social

Security Act (42 U.S.C. Section 1395 et seq. or Section 1396 et

seq.).

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 4201.053. MEDICAID AND CERTAIN OTHER STATE HEALTH OR MENTAL

HEALTH PROGRAMS. 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 special health care

needs under Chapter 35, Health and Safety Code;

(3) a program administered under Title 2, Human Resources Code;

(4) a program of the Department of State Health Services

relating to mental health services;

(5) a program of the Department of Aging and Disability Services

relating to mental retardation services; or

(6) a program of the Texas Department of Criminal Justice.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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' compensation medical benefits under Title 5, Labor Code.

The commissioner of workers' compensation shall regulate as

provided by this chapter a person who performs utilization review

of a medical benefit provided under Title 5, Labor Code.

(b) Repealed by Acts 2007, 80th Leg., R.S., Ch. 730, Sec.

3B.075(b), eff. September 1, 2007.

(c) Title 5, Labor Code, prevails in the event of a conflict

between this chapter and Title 5, Labor Code.

(d) The commissioner of workers' compensation may adopt rules as

necessary to implement this section.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Amended by:

Acts 2007, 80th Leg., R.S., Ch.

134, Sec. 7(a), eff. September 1, 2007.

Acts 2007, 80th Leg., R.S., Ch.

134, Sec. 7(b), eff. September 1, 2007.

Acts 2007, 80th Leg., R.S., Ch.

730, Sec. 3B.075(a), eff. September 1, 2007.

Acts 2007, 80th Leg., R.S., Ch.

730, Sec. 3B.075(b), eff. September 1, 2007.

Acts 2007, 80th Leg., R.S., Ch.

921, Sec. 9.075(a), eff. September 1, 2007.

Acts 2007, 80th Leg., R.S., Ch.

921, Sec. 9.075(b), eff. September 1, 2007.

Sec. 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 Chapter

2301 or Article 5.13-2 or that is issued under Chapter 981.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 Security Act of 1974 (29 U.S.C. Section 1002(1)).

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 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.

(b) This chapter applies to a health maintenance organization

except as expressly provided by this section.

(c) As a condition of holding a certificate of authority to

engage in the business of a health maintenance organization, a

health maintenance organization that performs utilization review

must:

(1) comply with this chapter, except Subchapter C; and

(2) submit to assessment of a maintenance tax under Chapter 258

to cover the costs of administering compliance with this

subsection.

(d) The commissioner shall adopt rules for appropriate

verification and enforcement of compliance with Subsection (c).

(e) Notwithstanding Subsection (c)(1), a health maintenance

organization that performs utilization review for a person or

entity subject to this chapter, other than a person or entity for

which the health maintenance organization is the payor, must

obtain a certificate of registration under Subchapter C and shall

comply with all of the provisions of this chapter.

(f) This chapter does not prohibit or limit the distribution of

a portion 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 withholding arrangements to a participating

physician or participating health care provider for providing

health care services to an enrollee.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 as expressly

provided by this section. As a condition of holding a

certificate of authority to engage in the business of insurance,

an insurer that performs utilization review shall comply with

this chapter, except Subchapter C. The insurer is subject to

assessment of a maintenance tax under Chapter 257 to cover the

costs of administering compliance with this subsection.

(b) The commissioner shall adopt rules for appropriate

verification and enforcement of compliance with Subsection (a).

(c) Notwithstanding Subsection (a), an insurer subject to this

code that performs utilization review for a person or entity

subject to this chapter, other than a person or entity for which

the insurer is the payor, must obtain a certificate of

registration under Subchapter C and shall comply with all of the

provisions of this chapter.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

SUBCHAPTER C. CERTIFICATION

Sec. 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 Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 rules adopted by the commissioner.

(b) As a condition of holding a certificate of registration or

renewal of a certificate, a utilization review agent must

maintain compliance with Subchapters D, E, and F.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 set

by the commissioner.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 initial certification

must require:

(1) the utilization review agent'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;

(4) information concerning the categories of personnel who will

perform utilization review for the agent;

(5) a copy of the procedures established under Subchapter H for

the appeal of an adverse determination;

(6) a certification that the agent will comply with this

chapter; and

(7) a copy of the procedures for resolving oral or written

complaints initiated by enrollees, patients, or health care

providers as required by Section 4201.204.

(b) The commissioner may not require that the summary of the

utilization review plan include proprietary details.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 cover the cost of administering this chapter.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 4201.106. CERTIFICATE NOT TRANSFERABLE. A certificate of

registration is not transferable.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 day after the date the change takes effect.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 the renewal date of the certificate.

(b) The commissioner shall provide the list at cost to each

individual or organization requesting the list.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

SUBCHAPTER D. UTILIZATION REVIEW: GENERAL STANDARDS

Sec. 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 with input from

appropriate health care providers and approved by a physician.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 United States.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 involvement

from physicians, including practicing physicians, dentists, and

other health care providers.

(b) A utilization review determination shall be made in

accordance with currently accepted medical or health care

practices, taking into account special circumstances of the case

that may require deviation from the norm stated in the screening

criteria.

(c) Screening criteria must be:

(1) objective;

(2) clinically valid;

(3) compatible with established principles of health care; and

(4) flexible enough to allow a deviation from the norm when

justified on a case-by-case basis.

(d) Screening criteria must be used to determine only whether to

approve the requested treatment. A denial of requested treatment

must be referred to an appropriate physician, dentist, or other

health care provider to determine medical necessity.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 as considered necessary by the commissioner; and

(2) copying as necessary for the commissioner to accomplish the

commissioner's duties under this code.

(b) Any information obtained or acquired under the authority of

this section, Section 4201.153, and this chapter is confidential

and privileged and is not subject to Chapter 552, Government

Code, or to subpoena except to the extent necessary for the

commissioner to enforce this chapter.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 insurance policy or

health benefit plan.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

SUBCHAPTER E. UTILIZATION REVIEW: RELATIONS WITH PATIENTS AND

HEALTH CARE PROVIDERS

Sec. 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 the frequency of contacts or reviews on the

severity or complexity of the patient's condition or on necessary

treatment and discharge planning activity.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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, participating in, or otherwise

being present during a patient's examination, treatment,

procedure, or therapy.

(b) This subchapter, Subchapters D and F, and Section

4201.102(b) may not be construed to otherwise limit or deny

contact with a patient for purposes of conducting utilization

review unless otherwise specifically prohibited by law.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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

or the submission or review of a mental health therapist's

process or progress notes.

(b) Notwithstanding this section, a utilization review agent may

require submission of a patient's medical record summary.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 by enrollees, patients, or health

care providers concerning the utilization review.

(b) The complaint procedure must include a requirement that the

utilization review agent provide a written response to the

complainant within 30 days.

(c) A utilization review agent shall submit to the commissioner

a summary report of all complaints at the times and in the form

specified by the commissioner. The agent shall allow the

commissioner to examine the complaints and relevant documents at

any time.

(d) A utilization review agent shall maintain a record of each

complaint until the third anniversary of the date the complainant

filed the complaint.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 or data.

(b) A designation made under this section may not preclude a

utilization review agent or medical advisor from contacting a

health care provider or the provider's employees who are not

designated under this section under circumstances in which:

(1) a review might otherwise be unreasonably delayed; or

(2) the designated individual is unable to provide the necessary

data or information that the agent requests.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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

appropriateness, or the experimental or investigational nature,

of a health care service, the agent shall provide the health care

provider who ordered the service a reasonable opportunity to

discuss with a physician the patient's treatment plan and the

clinical basis for the agent's determination.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Amended by:

Acts 2009, 81st Leg., R.S., Ch.

1330, Sec. 9, eff. September 1, 2009.

Sec. 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 in writing, including the costs of copying and

transmitting requested patient records or other documents.

(b) A health care provider's charges for providing medical

information to a utilization review agent may not:

(1) exceed the cost of copying records regarding a workers'

compensation claim as set by rules adopted by the commissioner of

workers' compensation; or

(2) include any costs otherwise recouped as part of the charges

for health care.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Amended by:

Acts 2007, 80th Leg., R.S., Ch.

134, Sec. 8(a), eff. September 1, 2007.

Acts 2007, 80th Leg., R.S., Ch.

730, Sec. 3B.076(a), eff. September 1, 2007.

Acts 2007, 80th Leg., R.S., Ch.

921, Sec. 9.076(a), eff. September 1, 2007.

SUBCHAPTER F. UTILIZATION REVIEW: PERSONNEL

Sec. 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 to be reviewed were or are to be

provided. The delegation does not release the agent from the

full responsibility for compliance with this chapter, including

the conduct of those to whom utilization review has been

delegated.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 than a physician, who obtain oral or

written information directly from a patient's physician or other

health care provider regarding the patient's specific medical

condition, diagnosis, or treatment options or protocols must be a

nurse, physician assistant, or other health care provider

qualified to provide the requested service.

(c) This section may not be interpreted to require personnel who

perform clerical or administrative tasks to have the

qualifications prescribed by this section.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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,

condition employment of the agent's employees or agent

evaluations, or set employee or agent performance standards,

based on the amount of volume of adverse determinations,

reductions of or limitations on lengths of stay, benefits,

services, or charges, or the number or frequency of telephone

calls or other contacts with health care providers or patients,

that are inconsistent with this chapter.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

SUBCHAPTER G. NOTICE OF DETERMINATIONS

Sec. 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 enrollee or a person acting on the enrollee's behalf.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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

of the request for utilization review and the agent receives all

information necessary to complete the review.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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) a description of or the source of the screening criteria

used as guidelines in making the adverse determination; and

(4) a description of the procedure for the complaint and appeal

process, including notice to the enrollee of the enrollee's right

to appeal an adverse determination to an independent review

organization and of the procedures to obtain that review.

(b) For an enrollee who has a life-threatening condition, the

notice required by Subsection (a)(4) must include a description

of the enrollee's right to an immediate review by an independent

review organization and of the procedures to obtain that review.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 4201.304. TIME FOR NOTICE OF ADVERSE DETERMINATION. A

utilization review agent shall provide notice of an adverse

determination required by this subchapter as follows:

(1) with respect to a patient who is hospitalized at the time of

the adverse determination, within one working day by either

telephone or electronic transmission to the provider of record,

followed by a letter within three working days notifying the

patient and the provider of record of the adverse determination;

(2) with respect to a patient who is not hospitalized at the

time of the adverse determination, within three working days in

writing to the provider of record and the patient; or

(3) within the time appropriate to the circumstances relating to

the delivery of the services to the patient and to the patient's

condition, provided that when denying poststabilization care

subsequent to emergency treatment as requested by a treating

physician or other health care provider, the agent shall provide

the notice to the treating physician or other health care

provider not later than one hour after the time of the request.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 the retrospective utilization review in

writing to the provider of record and the patient within a

reasonable period, but not later than 30 days after the date on

which the claim is received.

(b) The period under Subsection (a) may be extended once by the

utilization review agent for a period not to exceed 15 days, if

the utilization review agent:

(1) determines that an extension is necessary due to matters

beyond the utilization review agent's control; and

(2) notifies the provider of record and the patient before the

expiration of the initial 30-day period of the circumstances

requiring the extension and the date by which the utilization

review agent expects to make a determination.

(c) If the extension under Subsection (b) is required because of

the failure of the provider of record or the patient to submit

information necessary to reach a determination on the request,

the notice of extension must:

(1) specifically describe the required information necessary to

complete the request; and

(2) give the provider of record and the patient at least 45 days

from the date of receipt of the notice of extension to provide

the specified information.

(d) If the period for making the determination under this

section is extended because of the failure of the provider of

record or the patient to submit the information necessary to make

the determination, the period for making the determination is

tolled from the date on which the utilization review agent sends

the notification of the extension to the provider of record or

the patient until the earlier of:

(1) the date on which the provider of record or the patient

responds to the request for additional information; or

(2) the date by which the specified information was to have been

submitted.

(e) If the periods for retrospective utilization review provided

by this section conflict with the time limits concerning or

related to payment of claims established under Subchapter J,

Chapter 843, the time limits established under Subchapter J,

Chapter 843, control.

(f) If the periods for retrospective utilization review provided

by this section conflict with the time limits concerning or

related to payment of claims established under Subchapters C and

C-1, Chapter 1301, the time limits established under Subchapters

C and C-1, Chapter 1301, control.

(g) If the periods for retrospective utilization review provided

by this section conflict with the time limits concerning or

related to payment of claims established under Section 408.027,

Labor Code, the time limits established under Section 408.027,

Labor Code, control.

Added by Acts 2009, 81st Leg., R.S., Ch.

1330, Sec. 10, eff. September 1, 2009.

SUBCHAPTER H. APPEAL OF ADVERSE DETERMINATION

Sec. 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 Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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, Sec. 4, eff. April 1, 2007.

Sec. 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) a person acting on the enrollee's behalf; or

(3) the enrollee's physician or other health care provider.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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, the agent shall send to the appealing party

a letter acknowledging the date of receipt.

(b) The letter must also include a list of:

(1) the procedures required by this subchapter; and

(2) the documents that the appealing party must submit for

review.

(c) When a utilization review agent receives an oral appeal of

an adverse determination, the agent shall send a one-page appeal

form to the appealing party.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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).

(b) If not later than the 10th working day after the date an

appeal is denied the enrollee's health care provider states in

writing good cause for having a particular type of specialty

provider review the case, a health care provider who is of the

same or a similar specialty as the health care provider who would

typically manage the medical or dental condition, procedure, or

treatment under consideration for review shall review the

decision denying the appeal. The specialty review must be

completed within 15 working days of the date the health care

provider's request for specialty review is received.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 4201.357. EXPEDITED APPEAL FOR DENIAL OF EMERGENCY CARE OR

CONTINUED HOSPITALIZATION. (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 of

emergency care or a denial of continued hospitalization. That

procedure must include a review by a health care provider who:

(1) has not previously reviewed the case; and

(2) is of the same or a similar specialty as the health care

provider who would typically manage the medical or dental

condition, procedure, or treatment under review in the appeal.

(b) The time for resolution of an expedited appeal under this

section shall be based on the medical or dental immediacy of the

condition, procedure, or treatment under review, provided that

the resolution of the appeal may not exceed one working day from

the date all information necessary to complete the appeal is

received.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 a response letter explaining the

resolution of the appeal to:

(1) the patient or a person acting on the patient's behalf; and

(2) the patient's physician or other health care provider.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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

practicable, but not later than the 30th calendar day, after the

date the utilization review agent receives the appeal.

(b) If the appeal is denied, the notice must include a clear and

concise statement of:

(1) the clinical basis for the denial;

(2) the specialty of the physician or other health care provider

making the denial; and

(3) the appealing party's right to seek review of the denial by

an independent review organization under Subchapter I and the

procedures for obtaining that review.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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

organization as provided by Subchapter I; and

(2) not required to comply with procedures for an internal

review of the utilization review agent's adverse determination.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

SUBCHAPTER I. INDEPENDENT REVIEW OF ADVERSE DETERMINATION

Sec. 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

determination by an independent review organization assigned to

the appeal in accordance with Chapter 4202.

(b) The utilization review agent shall comply with the

independent review organization's determination regarding the

medical necessity or appropriateness of health care items and

services for an enrollee.

(c) The utilization review agent shall comply with the

independent review organization's determination regarding the

experimental or investigational nature of health care items and

services for an enrollee.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Amended by:

Acts 2009, 81st Leg., R.S., Ch.

1330, Sec. 11, eff. September 1, 2009.

Sec. 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 to the appropriate

independent review organization:

(1) 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;

(C) the written notification described by Section 4201.359; and

(D) any documents and other written information submitted to the

agent in support of the appeal; and

(2) a list of each physician or other health care provider who:

(A) has provided care to the enrollee; and

(B) may have medical records relevant to the appeal.

(b) A utilization review agent may provide confidential

information in the custody of the agent to an independent review

organization, subject to rules and standards adopted by the

commissioner under Chapter 4202.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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, Sec. 4, eff. April 1, 2007.

SUBCHAPTER J. SPECIALTY UTILIZATION REVIEW AGENTS

Sec. 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 dentistry, chiropractic services, or physical

therapy.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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, Sec. 4, eff. April 1, 2007.

Sec. 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 and conducted in accordance

with standards developed with input from a health care provider

of the appropriate specialty.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 agent and who is

licensed or otherwise authorized to provide the specialty health

care service by a state licensing agency in the United States.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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.

(b) Personnel who obtain oral or written information directly

from a physician or other health care provider must be a nurse,

physician assistant, or other health care provider of the same

specialty as the agent and who are licensed or otherwise

authorized to provide the specialty health care service by a

state licensing agency in the United States.

(c) This section does not require personnel who perform only

clerical or administrative tasks to have the qualifications

prescribed by this section.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 or

appropriateness, or the experimental or investigational nature,

of a health care service, the agent shall provide the health care

provider who ordered the service a reasonable opportunity to

discuss the patient's treatment plan and the clinical basis for

the agent's determination with a health care provider who is of

the same specialty as the agent.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Amended by:

Acts 2009, 81st Leg., R.S., Ch.

1330, Sec. 12, eff. September 1, 2009.

Sec. 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 of an

adverse determination must be of the same or a similar specialty

as the health care provider who would typically manage the

specialty condition, procedure, or treatment under review in the

appeal.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

SUBCHAPTER L. CONFIDENTIALITY OF INFORMATION; ACCESS TO OTHER

INFORMATION

Sec. 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 a utilization review agent

to take any action that violates a state or federal law or

regulation concerning confidentiality of patient records.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 utilization review without the

patient's prior written consent or except as otherwise required

by law.

(b) If the prior written consent is submitted by anyone other

than the patient who is the subject of the personal or

confidential information requested, the consent must:

(1) be dated; and

(2) contain the patient's signature.

(c) The patient's signature for purposes of Subsection (b)(2)

must have been obtained one year or less before the date the

disclosure is sought or the consent is invalid.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 with utilization review. Information

provided to a third party under this section remains

confidential.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 to

determine compliance with this chapter. The information is

confidential and privileged and is not subject to Chapter 552,

Government Code, or to subpoena, except to the extent necessary

to enable the commissioner to enforce this chapter.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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, within 10 business days from the

date the agent receives the request:

(1) inform the requesting individual in writing of the nature

and substance of the recorded personal information; and

(2) allow the individual, at the individual's discretion, to:

(A) view and copy, in person, the recorded personal information

concerning the individual; or

(B) obtain a copy of the information by mail.

(b) If the information requested under this section is in coded

form, the utilization review agent shall provide in writing an

accurate translation of the information in plain language.

(c) A utilization review agent's charges for providing a copy of

information requested under this section shall be reasonable, as

determined by rule adopted by the commissioner. The charges may

not include any costs otherwise recouped as part of the charges

for utilization review.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 study or performance

tracking data, without providing prior written notice to the

physician or other provider.

(b) The prohibition under this section does not apply to

internal systems or reports used by the utilization review agent.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 disclosure to

a third party.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 care

provider financial data is no longer needed, the document shall

be destroyed by a method that ensures the complete destruction of

the information.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

SUBCHAPTER M. ENFORCEMENT

Sec. 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 notify the utilization review agent, health

maintenance organization, or insurer of the alleged violation;

and

(2) may compel the production of documents or other information

as necessary to determine whether a violation has occurred.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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, Government Code.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 violating this

chapter, the commissioner may:

(1) impose a sanction under Chapter 82;

(2) issue a cease and desist order under Chapter 83; or

(3) assess an administrative penalty under Chapter 84.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.


State Codes and Statutes

State Codes and Statutes

Statutes > Texas > Insurance-code > Title-14-utilization-review-and-independent-review > Chapter-4201-utilization-review-agents

INSURANCE CODE

TITLE 14. UTILIZATION REVIEW AND INDEPENDENT REVIEW

CHAPTER 4201. UTILIZATION REVIEW AGENTS

SUBCHAPTER A. GENERAL PROVISIONS

Sec. 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 agent adheres to reasonable

standards for conducting utilization review;

(3) foster greater coordination and cooperation between a health

care provider and utilization review agent;

(4) improve communications and knowledge of benefits among all

parties concerned before an expense is incurred; and

(5) ensure that a utilization review agent maintains the

confidentiality of medical records in accordance with applicable

law.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 a patient are not medically necessary

or are experimental or investigational.

(2) "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 severe pain, that would lead a prudent layperson

possessing an average knowledge of medicine and health to believe

that the individual's condition, sickness, or injury is of such a

nature that failure to get immediate medical care could:

(A) place the individual's health in serious jeopardy;

(B) result in serious impairment to bodily functions;

(C) result in serious dysfunction of a bodily organ or part;

(D) result in serious disfigurement; or

(E) for a pregnant woman, result in serious jeopardy to the

health of the fetus.

(3) "Enrollee" means an individual covered by a health

insurance policy or health benefit plan. The term includes an

individual who is covered as an eligible dependent of another

individual.

(4) "Health benefit plan" means a plan of benefits, other than a

health insurance policy, that:

(A) defines the coverage provisions for health care for

enrollees; and

(B) is offered or provided by a public or private organization.

(5) "Health care provider" means a person, corporation,

facility, or institution that is:

(A) licensed by a state to provide or is otherwise lawfully

providing health care services; and

(B) eligible for independent reimbursement for those health care

services.

(6) "Health insurance policy" means an insurance policy,

including a policy written by a corporation subject to Chapter

842, that provides coverage for medical or surgical expenses

incurred as a result of accident or sickness.

(7) "Life-threatening" means a disease or condition from which

the likelihood of death is probable unless the course of the

disease or condition is interrupted.

(8) "Nurse" means a professional or registered nurse, a licensed

vocational nurse, or a licensed practical nurse.

(9) "Patient" means the enrollee or an eligible dependent of the

enrollee under a health benefit plan or health insurance policy.

(10) "Payor" means:

(A) an insurer that writes health insurance policies;

(B) a preferred provider organization, health maintenance

organization, or self-insurance plan; or

(C) any other person or entity that provides, offers to provide,

or administers hospital, outpatient, medical, or other health

benefits to a person treated by a health care provider in this

state under a policy, plan, or contract.

(11) "Physician" means a licensed doctor of medicine or a doctor

of osteopathy.

(12) "Provider of record" means the physician or other health

care provider with primary responsibility for the care,

treatment, and services provided to an enrollee. The term

includes a health care facility if treatment is provided on an

inpatient or outpatient basis.

(13) "Utilization review" includes a system for prospective,

concurrent, or retrospective review of the medical necessity and

appropriateness of health care services and a system for

prospective, concurrent, or retrospective review to determine the

experimental or investigational nature of health care services.

The term does not include a review in response to an elective

request for clarification of coverage.

(14) "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 holding a certificate of authority under

Chapter 4151.

(15) "Utilization review plan" means the screening criteria and

utilization review procedures of a utilization review agent.

(16) "Working day" means a weekday that is not a legal holiday.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Amended by:

Acts 2009, 81st Leg., R.S., Ch.

1330, Sec. 7, eff. September 1, 2009.

Sec. 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 to this chapter.

(c) The commissioner shall appoint an advisory committee to

advise the commissioner on development of rules regarding the

administration of this chapter, as authorized by Section

2001.031, Government Code. The committee includes:

(1) the public counsel appointed under Chapter 501; and

(2) one representative for each of the following:

(A) insurers;

(B) health maintenance organizations;

(C) group hospital service corporations;

(D) utilization review agents;

(E) employers;

(F) consumer organizations;

(G) physicians;

(H) dentists;

(I) hospitals;

(J) registered nurses; and

(K) other health care providers.

(d) The advisory committee's deliberations are subject to

Chapter 551, Government Code.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 in this state, to discuss patients' care and allow

response to telephone review requests;

(2) have a telephone system capable, during hours other than

normal business hours, of accepting or recording incoming

telephone calls or of providing instructions to a caller; and

(3) respond to a call made during hours other than normal

business hours not later than the second working day after the

later of:

(A) the date the call was received; or

(B) the date the details necessary to respond have been received

from the caller.

(b) A utilization review agent must provide to the commissioner

a written description of the procedures to be used when

responding with respect to poststabilization care subsequent to

emergency treatment as requested by a treating physician or other

health care provider.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

SUBCHAPTER B. APPLICABILITY OF CHAPTER

Sec. 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 insurance policy or health

benefit plan; and

(2) does not determine whether a particular health care service

provided or to be provided to an enrollee is:

(A) medically necessary or appropriate; or

(B) experimental or investigational.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Amended by:

Acts 2009, 81st Leg., R.S., Ch.

1330, Sec. 8, eff. September 1, 2009.

Sec. 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 services under Title XVIII or XIX of the Social

Security Act (42 U.S.C. Section 1395 et seq. or Section 1396 et

seq.).

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 4201.053. MEDICAID AND CERTAIN OTHER STATE HEALTH OR MENTAL

HEALTH PROGRAMS. 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 special health care

needs under Chapter 35, Health and Safety Code;

(3) a program administered under Title 2, Human Resources Code;

(4) a program of the Department of State Health Services

relating to mental health services;

(5) a program of the Department of Aging and Disability Services

relating to mental retardation services; or

(6) a program of the Texas Department of Criminal Justice.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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' compensation medical benefits under Title 5, Labor Code.

The commissioner of workers' compensation shall regulate as

provided by this chapter a person who performs utilization review

of a medical benefit provided under Title 5, Labor Code.

(b) Repealed by Acts 2007, 80th Leg., R.S., Ch. 730, Sec.

3B.075(b), eff. September 1, 2007.

(c) Title 5, Labor Code, prevails in the event of a conflict

between this chapter and Title 5, Labor Code.

(d) The commissioner of workers' compensation may adopt rules as

necessary to implement this section.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Amended by:

Acts 2007, 80th Leg., R.S., Ch.

134, Sec. 7(a), eff. September 1, 2007.

Acts 2007, 80th Leg., R.S., Ch.

134, Sec. 7(b), eff. September 1, 2007.

Acts 2007, 80th Leg., R.S., Ch.

730, Sec. 3B.075(a), eff. September 1, 2007.

Acts 2007, 80th Leg., R.S., Ch.

730, Sec. 3B.075(b), eff. September 1, 2007.

Acts 2007, 80th Leg., R.S., Ch.

921, Sec. 9.075(a), eff. September 1, 2007.

Acts 2007, 80th Leg., R.S., Ch.

921, Sec. 9.075(b), eff. September 1, 2007.

Sec. 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 Chapter

2301 or Article 5.13-2 or that is issued under Chapter 981.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 Security Act of 1974 (29 U.S.C. Section 1002(1)).

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 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.

(b) This chapter applies to a health maintenance organization

except as expressly provided by this section.

(c) As a condition of holding a certificate of authority to

engage in the business of a health maintenance organization, a

health maintenance organization that performs utilization review

must:

(1) comply with this chapter, except Subchapter C; and

(2) submit to assessment of a maintenance tax under Chapter 258

to cover the costs of administering compliance with this

subsection.

(d) The commissioner shall adopt rules for appropriate

verification and enforcement of compliance with Subsection (c).

(e) Notwithstanding Subsection (c)(1), a health maintenance

organization that performs utilization review for a person or

entity subject to this chapter, other than a person or entity for

which the health maintenance organization is the payor, must

obtain a certificate of registration under Subchapter C and shall

comply with all of the provisions of this chapter.

(f) This chapter does not prohibit or limit the distribution of

a portion 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 withholding arrangements to a participating

physician or participating health care provider for providing

health care services to an enrollee.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 as expressly

provided by this section. As a condition of holding a

certificate of authority to engage in the business of insurance,

an insurer that performs utilization review shall comply with

this chapter, except Subchapter C. The insurer is subject to

assessment of a maintenance tax under Chapter 257 to cover the

costs of administering compliance with this subsection.

(b) The commissioner shall adopt rules for appropriate

verification and enforcement of compliance with Subsection (a).

(c) Notwithstanding Subsection (a), an insurer subject to this

code that performs utilization review for a person or entity

subject to this chapter, other than a person or entity for which

the insurer is the payor, must obtain a certificate of

registration under Subchapter C and shall comply with all of the

provisions of this chapter.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

SUBCHAPTER C. CERTIFICATION

Sec. 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 Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 rules adopted by the commissioner.

(b) As a condition of holding a certificate of registration or

renewal of a certificate, a utilization review agent must

maintain compliance with Subchapters D, E, and F.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 set

by the commissioner.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 initial certification

must require:

(1) the utilization review agent'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;

(4) information concerning the categories of personnel who will

perform utilization review for the agent;

(5) a copy of the procedures established under Subchapter H for

the appeal of an adverse determination;

(6) a certification that the agent will comply with this

chapter; and

(7) a copy of the procedures for resolving oral or written

complaints initiated by enrollees, patients, or health care

providers as required by Section 4201.204.

(b) The commissioner may not require that the summary of the

utilization review plan include proprietary details.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 cover the cost of administering this chapter.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 4201.106. CERTIFICATE NOT TRANSFERABLE. A certificate of

registration is not transferable.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 day after the date the change takes effect.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 the renewal date of the certificate.

(b) The commissioner shall provide the list at cost to each

individual or organization requesting the list.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

SUBCHAPTER D. UTILIZATION REVIEW: GENERAL STANDARDS

Sec. 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 with input from

appropriate health care providers and approved by a physician.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 United States.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 involvement

from physicians, including practicing physicians, dentists, and

other health care providers.

(b) A utilization review determination shall be made in

accordance with currently accepted medical or health care

practices, taking into account special circumstances of the case

that may require deviation from the norm stated in the screening

criteria.

(c) Screening criteria must be:

(1) objective;

(2) clinically valid;

(3) compatible with established principles of health care; and

(4) flexible enough to allow a deviation from the norm when

justified on a case-by-case basis.

(d) Screening criteria must be used to determine only whether to

approve the requested treatment. A denial of requested treatment

must be referred to an appropriate physician, dentist, or other

health care provider to determine medical necessity.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 as considered necessary by the commissioner; and

(2) copying as necessary for the commissioner to accomplish the

commissioner's duties under this code.

(b) Any information obtained or acquired under the authority of

this section, Section 4201.153, and this chapter is confidential

and privileged and is not subject to Chapter 552, Government

Code, or to subpoena except to the extent necessary for the

commissioner to enforce this chapter.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 insurance policy or

health benefit plan.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

SUBCHAPTER E. UTILIZATION REVIEW: RELATIONS WITH PATIENTS AND

HEALTH CARE PROVIDERS

Sec. 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 the frequency of contacts or reviews on the

severity or complexity of the patient's condition or on necessary

treatment and discharge planning activity.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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, participating in, or otherwise

being present during a patient's examination, treatment,

procedure, or therapy.

(b) This subchapter, Subchapters D and F, and Section

4201.102(b) may not be construed to otherwise limit or deny

contact with a patient for purposes of conducting utilization

review unless otherwise specifically prohibited by law.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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

or the submission or review of a mental health therapist's

process or progress notes.

(b) Notwithstanding this section, a utilization review agent may

require submission of a patient's medical record summary.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 by enrollees, patients, or health

care providers concerning the utilization review.

(b) The complaint procedure must include a requirement that the

utilization review agent provide a written response to the

complainant within 30 days.

(c) A utilization review agent shall submit to the commissioner

a summary report of all complaints at the times and in the form

specified by the commissioner. The agent shall allow the

commissioner to examine the complaints and relevant documents at

any time.

(d) A utilization review agent shall maintain a record of each

complaint until the third anniversary of the date the complainant

filed the complaint.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 or data.

(b) A designation made under this section may not preclude a

utilization review agent or medical advisor from contacting a

health care provider or the provider's employees who are not

designated under this section under circumstances in which:

(1) a review might otherwise be unreasonably delayed; or

(2) the designated individual is unable to provide the necessary

data or information that the agent requests.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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

appropriateness, or the experimental or investigational nature,

of a health care service, the agent shall provide the health care

provider who ordered the service a reasonable opportunity to

discuss with a physician the patient's treatment plan and the

clinical basis for the agent's determination.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Amended by:

Acts 2009, 81st Leg., R.S., Ch.

1330, Sec. 9, eff. September 1, 2009.

Sec. 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 in writing, including the costs of copying and

transmitting requested patient records or other documents.

(b) A health care provider's charges for providing medical

information to a utilization review agent may not:

(1) exceed the cost of copying records regarding a workers'

compensation claim as set by rules adopted by the commissioner of

workers' compensation; or

(2) include any costs otherwise recouped as part of the charges

for health care.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Amended by:

Acts 2007, 80th Leg., R.S., Ch.

134, Sec. 8(a), eff. September 1, 2007.

Acts 2007, 80th Leg., R.S., Ch.

730, Sec. 3B.076(a), eff. September 1, 2007.

Acts 2007, 80th Leg., R.S., Ch.

921, Sec. 9.076(a), eff. September 1, 2007.

SUBCHAPTER F. UTILIZATION REVIEW: PERSONNEL

Sec. 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 to be reviewed were or are to be

provided. The delegation does not release the agent from the

full responsibility for compliance with this chapter, including

the conduct of those to whom utilization review has been

delegated.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 than a physician, who obtain oral or

written information directly from a patient's physician or other

health care provider regarding the patient's specific medical

condition, diagnosis, or treatment options or protocols must be a

nurse, physician assistant, or other health care provider

qualified to provide the requested service.

(c) This section may not be interpreted to require personnel who

perform clerical or administrative tasks to have the

qualifications prescribed by this section.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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,

condition employment of the agent's employees or agent

evaluations, or set employee or agent performance standards,

based on the amount of volume of adverse determinations,

reductions of or limitations on lengths of stay, benefits,

services, or charges, or the number or frequency of telephone

calls or other contacts with health care providers or patients,

that are inconsistent with this chapter.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

SUBCHAPTER G. NOTICE OF DETERMINATIONS

Sec. 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 enrollee or a person acting on the enrollee's behalf.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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

of the request for utilization review and the agent receives all

information necessary to complete the review.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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) a description of or the source of the screening criteria

used as guidelines in making the adverse determination; and

(4) a description of the procedure for the complaint and appeal

process, including notice to the enrollee of the enrollee's right

to appeal an adverse determination to an independent review

organization and of the procedures to obtain that review.

(b) For an enrollee who has a life-threatening condition, the

notice required by Subsection (a)(4) must include a description

of the enrollee's right to an immediate review by an independent

review organization and of the procedures to obtain that review.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 4201.304. TIME FOR NOTICE OF ADVERSE DETERMINATION. A

utilization review agent shall provide notice of an adverse

determination required by this subchapter as follows:

(1) with respect to a patient who is hospitalized at the time of

the adverse determination, within one working day by either

telephone or electronic transmission to the provider of record,

followed by a letter within three working days notifying the

patient and the provider of record of the adverse determination;

(2) with respect to a patient who is not hospitalized at the

time of the adverse determination, within three working days in

writing to the provider of record and the patient; or

(3) within the time appropriate to the circumstances relating to

the delivery of the services to the patient and to the patient's

condition, provided that when denying poststabilization care

subsequent to emergency treatment as requested by a treating

physician or other health care provider, the agent shall provide

the notice to the treating physician or other health care

provider not later than one hour after the time of the request.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 the retrospective utilization review in

writing to the provider of record and the patient within a

reasonable period, but not later than 30 days after the date on

which the claim is received.

(b) The period under Subsection (a) may be extended once by the

utilization review agent for a period not to exceed 15 days, if

the utilization review agent:

(1) determines that an extension is necessary due to matters

beyond the utilization review agent's control; and

(2) notifies the provider of record and the patient before the

expiration of the initial 30-day period of the circumstances

requiring the extension and the date by which the utilization

review agent expects to make a determination.

(c) If the extension under Subsection (b) is required because of

the failure of the provider of record or the patient to submit

information necessary to reach a determination on the request,

the notice of extension must:

(1) specifically describe the required information necessary to

complete the request; and

(2) give the provider of record and the patient at least 45 days

from the date of receipt of the notice of extension to provide

the specified information.

(d) If the period for making the determination under this

section is extended because of the failure of the provider of

record or the patient to submit the information necessary to make

the determination, the period for making the determination is

tolled from the date on which the utilization review agent sends

the notification of the extension to the provider of record or

the patient until the earlier of:

(1) the date on which the provider of record or the patient

responds to the request for additional information; or

(2) the date by which the specified information was to have been

submitted.

(e) If the periods for retrospective utilization review provided

by this section conflict with the time limits concerning or

related to payment of claims established under Subchapter J,

Chapter 843, the time limits established under Subchapter J,

Chapter 843, control.

(f) If the periods for retrospective utilization review provided

by this section conflict with the time limits concerning or

related to payment of claims established under Subchapters C and

C-1, Chapter 1301, the time limits established under Subchapters

C and C-1, Chapter 1301, control.

(g) If the periods for retrospective utilization review provided

by this section conflict with the time limits concerning or

related to payment of claims established under Section 408.027,

Labor Code, the time limits established under Section 408.027,

Labor Code, control.

Added by Acts 2009, 81st Leg., R.S., Ch.

1330, Sec. 10, eff. September 1, 2009.

SUBCHAPTER H. APPEAL OF ADVERSE DETERMINATION

Sec. 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 Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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, Sec. 4, eff. April 1, 2007.

Sec. 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) a person acting on the enrollee's behalf; or

(3) the enrollee's physician or other health care provider.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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, the agent shall send to the appealing party

a letter acknowledging the date of receipt.

(b) The letter must also include a list of:

(1) the procedures required by this subchapter; and

(2) the documents that the appealing party must submit for

review.

(c) When a utilization review agent receives an oral appeal of

an adverse determination, the agent shall send a one-page appeal

form to the appealing party.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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).

(b) If not later than the 10th working day after the date an

appeal is denied the enrollee's health care provider states in

writing good cause for having a particular type of specialty

provider review the case, a health care provider who is of the

same or a similar specialty as the health care provider who would

typically manage the medical or dental condition, procedure, or

treatment under consideration for review shall review the

decision denying the appeal. The specialty review must be

completed within 15 working days of the date the health care

provider's request for specialty review is received.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 4201.357. EXPEDITED APPEAL FOR DENIAL OF EMERGENCY CARE OR

CONTINUED HOSPITALIZATION. (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 of

emergency care or a denial of continued hospitalization. That

procedure must include a review by a health care provider who:

(1) has not previously reviewed the case; and

(2) is of the same or a similar specialty as the health care

provider who would typically manage the medical or dental

condition, procedure, or treatment under review in the appeal.

(b) The time for resolution of an expedited appeal under this

section shall be based on the medical or dental immediacy of the

condition, procedure, or treatment under review, provided that

the resolution of the appeal may not exceed one working day from

the date all information necessary to complete the appeal is

received.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 a response letter explaining the

resolution of the appeal to:

(1) the patient or a person acting on the patient's behalf; and

(2) the patient's physician or other health care provider.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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

practicable, but not later than the 30th calendar day, after the

date the utilization review agent receives the appeal.

(b) If the appeal is denied, the notice must include a clear and

concise statement of:

(1) the clinical basis for the denial;

(2) the specialty of the physician or other health care provider

making the denial; and

(3) the appealing party's right to seek review of the denial by

an independent review organization under Subchapter I and the

procedures for obtaining that review.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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

organization as provided by Subchapter I; and

(2) not required to comply with procedures for an internal

review of the utilization review agent's adverse determination.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

SUBCHAPTER I. INDEPENDENT REVIEW OF ADVERSE DETERMINATION

Sec. 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

determination by an independent review organization assigned to

the appeal in accordance with Chapter 4202.

(b) The utilization review agent shall comply with the

independent review organization's determination regarding the

medical necessity or appropriateness of health care items and

services for an enrollee.

(c) The utilization review agent shall comply with the

independent review organization's determination regarding the

experimental or investigational nature of health care items and

services for an enrollee.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Amended by:

Acts 2009, 81st Leg., R.S., Ch.

1330, Sec. 11, eff. September 1, 2009.

Sec. 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 to the appropriate

independent review organization:

(1) 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;

(C) the written notification described by Section 4201.359; and

(D) any documents and other written information submitted to the

agent in support of the appeal; and

(2) a list of each physician or other health care provider who:

(A) has provided care to the enrollee; and

(B) may have medical records relevant to the appeal.

(b) A utilization review agent may provide confidential

information in the custody of the agent to an independent review

organization, subject to rules and standards adopted by the

commissioner under Chapter 4202.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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, Sec. 4, eff. April 1, 2007.

SUBCHAPTER J. SPECIALTY UTILIZATION REVIEW AGENTS

Sec. 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 dentistry, chiropractic services, or physical

therapy.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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, Sec. 4, eff. April 1, 2007.

Sec. 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 and conducted in accordance

with standards developed with input from a health care provider

of the appropriate specialty.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 agent and who is

licensed or otherwise authorized to provide the specialty health

care service by a state licensing agency in the United States.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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.

(b) Personnel who obtain oral or written information directly

from a physician or other health care provider must be a nurse,

physician assistant, or other health care provider of the same

specialty as the agent and who are licensed or otherwise

authorized to provide the specialty health care service by a

state licensing agency in the United States.

(c) This section does not require personnel who perform only

clerical or administrative tasks to have the qualifications

prescribed by this section.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 or

appropriateness, or the experimental or investigational nature,

of a health care service, the agent shall provide the health care

provider who ordered the service a reasonable opportunity to

discuss the patient's treatment plan and the clinical basis for

the agent's determination with a health care provider who is of

the same specialty as the agent.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Amended by:

Acts 2009, 81st Leg., R.S., Ch.

1330, Sec. 12, eff. September 1, 2009.

Sec. 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 of an

adverse determination must be of the same or a similar specialty

as the health care provider who would typically manage the

specialty condition, procedure, or treatment under review in the

appeal.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

SUBCHAPTER L. CONFIDENTIALITY OF INFORMATION; ACCESS TO OTHER

INFORMATION

Sec. 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 a utilization review agent

to take any action that violates a state or federal law or

regulation concerning confidentiality of patient records.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 utilization review without the

patient's prior written consent or except as otherwise required

by law.

(b) If the prior written consent is submitted by anyone other

than the patient who is the subject of the personal or

confidential information requested, the consent must:

(1) be dated; and

(2) contain the patient's signature.

(c) The patient's signature for purposes of Subsection (b)(2)

must have been obtained one year or less before the date the

disclosure is sought or the consent is invalid.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 with utilization review. Information

provided to a third party under this section remains

confidential.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 to

determine compliance with this chapter. The information is

confidential and privileged and is not subject to Chapter 552,

Government Code, or to subpoena, except to the extent necessary

to enable the commissioner to enforce this chapter.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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, within 10 business days from the

date the agent receives the request:

(1) inform the requesting individual in writing of the nature

and substance of the recorded personal information; and

(2) allow the individual, at the individual's discretion, to:

(A) view and copy, in person, the recorded personal information

concerning the individual; or

(B) obtain a copy of the information by mail.

(b) If the information requested under this section is in coded

form, the utilization review agent shall provide in writing an

accurate translation of the information in plain language.

(c) A utilization review agent's charges for providing a copy of

information requested under this section shall be reasonable, as

determined by rule adopted by the commissioner. The charges may

not include any costs otherwise recouped as part of the charges

for utilization review.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 study or performance

tracking data, without providing prior written notice to the

physician or other provider.

(b) The prohibition under this section does not apply to

internal systems or reports used by the utilization review agent.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 disclosure to

a third party.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 care

provider financial data is no longer needed, the document shall

be destroyed by a method that ensures the complete destruction of

the information.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

SUBCHAPTER M. ENFORCEMENT

Sec. 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 notify the utilization review agent, health

maintenance organization, or insurer of the alleged violation;

and

(2) may compel the production of documents or other information

as necessary to determine whether a violation has occurred.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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, Government Code.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.

Sec. 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 violating this

chapter, the commissioner may:

(1) impose a sanction under Chapter 82;

(2) issue a cease and desist order under Chapter 83; or

(3) assess an administrative penalty under Chapter 84.

Added by Acts 2005, 79th Leg., Ch.

727, Sec. 4, eff. April 1, 2007.