CHAPTER 4202. INDEPENDENT REVIEW ORGANIZATIONS

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Statutes > Texas > Insurance-code > Title-14-utilization-review-and-independent-review > Chapter-4202-independent-review-organizations

INSURANCE CODE

TITLE 14. UTILIZATION REVIEW AND INDEPENDENT REVIEW

Sec. 4202.001. DEFINITION. In this chapter, "payor" has the

meaning assigned by Section 4201.002.

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

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

Sec. 4202.002. ADOPTION OF STANDARDS FOR INDEPENDENT REVIEW

ORGANIZATIONS. (a) The commissioner shall adopt standards and

rules for:

(1) the certification, selection, and operation of independent

review organizations to perform independent review described by

Subchapter I, Chapter 4201; and

(2) the suspension and revocation of the certification.

(b) The standards adopted under this section must ensure:

(1) the timely response of an independent review organization

selected under this chapter;

(2) the confidentiality of medical records transmitted to an

independent review organization for use in conducting an

independent review;

(3) the qualifications and independence of each physician or

other health care provider making a review determination for an

independent review organization;

(4) the fairness of the procedures used by an independent review

organization in making review determinations; and

(5) the timely notice to an enrollee of the results of an

independent review, including the clinical basis for the review

determination.

the commissioner shall adopt standards and rules that:

(1) prohibit:

(A) more than one independent review organization from operating

out of the same office or other facility;

(B) an individual or entity from owning more than one

independent review organization;

of more than one independent review organization;

(D) an individual who has served on the board of an independent

review organization whose certification was revoked for cause

from serving on the board of another independent review

organization before the fifth anniversary of the date on which

the revocation occurred;

(E) an attorney who is, or has in the past served as, the

registered agent for an independent review organization from

representing the independent review organization in legal

proceedings; and

(F) an independent review organization from disclosing

confidential patient information, except to a provider who is

under contract to perform the review; and

(2) require:

(A) an independent review organization to be based and certified

in this state and to locate the organization's primary offices in

this state;

(B) an independent review organization to voluntarily surrender

the organization's certification while the organization is under

investigation or as part of an agreed order; and

a new certification after the organization is sold to a new

owner.

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

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

Amended by:

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

1332, Sec. 1, eff. September 1, 2009.

Sec. 4202.003. REQUIREMENTS REGARDING TIMELINESS OF

DETERMINATION. The standards adopted under Section 4202.002 must

require each independent review organization to make the

organization's determination:

(1) for a life-threatening condition as defined by Section

4201.002, not later than the earlier of:

(A) the fifth day after the date the organization receives the

information necessary to make the determination; or

(B) the eighth day after the date the organization receives the

request that the determination be made; and

(2) for a condition other than a life-threatening condition, not

later than the earlier of:

(A) the 15th day after the date the organization receives the

information necessary to make the determination; or

(B) the 20th day after the date the organization receives the

request that the determination be made.

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

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

Sec. 4202.004. CERTIFICATION. To be certified as an independent

review organization under this chapter, an organization must

submit to the commissioner an application in the form required by

the commissioner. The application must include:

(1) for an applicant that is publicly held, the name of each

shareholder or owner of more than five percent of any of the

applicant's stock or options;

(2) the name of any holder of the applicant's bonds or notes

that exceed $100,000;

(3) the name and type of business of each corporation or other

organization that the applicant controls or is affiliated with

and the nature and extent of the control or affiliation;

(4) the name and a biographical sketch of each director,

officer, and executive of the applicant and of any entity listed

under Subdivision (3) and a description of any relationship the

named individual has with:

(A) a health benefit plan;

(B) a health maintenance organization;

(D) a utilization review agent;

(E) a nonprofit health corporation;

(F) a payor;

(G) a health care provider; or

(H) a group representing any of the entities described by

Paragraphs (A) through (G);

(5) the percentage of the applicant's revenues that are

anticipated to be derived from independent reviews conducted

under Subchapter I, Chapter 4201;

(6) a description of the areas of expertise of the physicians or

other health care providers making review determinations for the

applicant; and

(7) the procedures to be used by the applicant in making

independent review determinations under Subchapter I, Chapter

4201.

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

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

Sec. 4202.005. PERIODIC REPORTING OF INFORMATION; ANNUAL

DESIGNATION. (a) An independent review organization shall

annually submit the information required in an application for

certification under Section 4202.004. Anytime there is a

material change in the information the organization included in

the application, the organization shall submit updated

information to the commissioner.

(b) The commissioner shall designate annually each organization

that meets the standards for an independent review organization

adopted under Section 4202.002.

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

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

Sec. 4202.006. PAYORS FEES. The commissioner shall charge

payors fees in accordance with this chapter as necessary to fund

the operations of independent review organizations.

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

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

Sec. 4202.007. OVERSIGHT. The commissioner shall provide

ongoing oversight of the independent review organizations to

ensure continued compliance with this chapter and the standards

and rules adopted under this chapter.

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

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

Sec. 4202.008. PROHIBITED OWNERSHIP OR CONTROL OF INDEPENDENT

REVIEW ORGANIZATION. An independent review organization may not

be a subsidiary of, or in any way owned or controlled by, a payor

or a trade or professional association of payors.

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

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

Sec. 4202.009. CONFIDENTIAL INFORMATION. Information that

reveals the identity of a physician or other individual health

care provider who makes a review determination for an independent

review organization is confidential.

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

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

Sec. 4202.010. IMMUNITY FROM LIABILITY. (a) An independent

review organization conducting an independent review under

Subchapter I, Chapter 4201, is not liable for damages arising

from the review determination made by the organization.

(b) This section does not apply to an act or omission of the

independent review organization that is made in bad faith or that

involves gross negligence.

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

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

State Codes and Statutes

State Codes and Statutes

State Codes and Statutes

State Codes and Statutes

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