reglab/housing_qa huggingface dataset:
TX Ins Code § 4201.104 (2021)
2021 Texas Statutes|Insurance Code|Title 14 - Utilization Review and Independent Review|Chapter 4201 - Utilization Review Agents|Subchapter C. Certification|Section 4201.104. Certification and Renewal Forms

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 (H.B. 2017), Sec. 4, eff. April 1, 2007.|
TX Ins Code § 4201.105 (2021)
2021 Texas Statutes|Insurance Code|Title 14 - Utilization Review and Independent Review|Chapter 4201 - Utilization Review Agents|Subchapter C. Certification|Section 4201.105. Fees

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 (H.B. 2017), Sec. 4, eff. April 1, 2007.|
TX Ins Code § 4201.106 (2021)
2021 Texas Statutes|Insurance Code|Title 14 - Utilization Review and Independent Review|Chapter 4201 - Utilization Review Agents|Subchapter C. Certification|Section 4201.106. Certificate Not Transferable

Sec. 4201.106.  CERTIFICATE NOT TRANSFERABLE.  A certificate of registration is not transferable.|Added by Acts 2005, 79th Leg., Ch. 727 (H.B. 2017), Sec. 4, eff. April 1, 2007.|
TX Ins Code § 4201.107 (2021)
2021 Texas Statutes|Insurance Code|Title 14 - Utilization Review and Independent Review|Chapter 4201 - Utilization Review Agents|Subchapter C. Certification|Section 4201.107. Reporting Material Changes

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 (H.B. 2017), Sec. 4, eff. April 1, 2007.|
TX Ins Code § 4201.108 (2021)
2021 Texas Statutes|Insurance Code|Title 14 - Utilization Review and Independent Review|Chapter 4201 - Utilization Review Agents|Subchapter C. Certification|Section 4201.108. List of Utilization Review Agents

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 (H.B. 2017), Sec. 4, eff. April 1, 2007.|
TX Ins Code § 4201.151 (2021)
2021 Texas Statutes|Insurance Code|Title 14 - Utilization Review and Independent Review|Chapter 4201 - Utilization Review Agents|Subchapter D. Utilization Review: General Standards|Section 4201.151. Utilization Review Plan

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 licensed to practice medicine in this state and conducted in accordance with standards developed with input from appropriate health care providers and approved by a physician licensed to practice medicine in this state.|Added by Acts 2005, 79th Leg., Ch. 727 (H.B. 2017), Sec. 4, eff. April 1, 2007.Amended by: Acts 2019, 86th Leg., R.S., Ch. 1218 (S.B. 1742), Sec. 3.02, eff. September 1, 2019.|
TX Ins Code § 4201.152 (2021)
2021 Texas Statutes|Insurance Code|Title 14 - Utilization Review and Independent Review|Chapter 4201 - Utilization Review Agents|Subchapter D. Utilization Review: General Standards|Section 4201.152. Utilization Review Under Physician

Sec. 4201.152.  UTILIZATION REVIEW UNDER PHYSICIAN.  A utilization review agent shall conduct utilization review under the direction of a physician licensed to practice medicine in this state.|Added by Acts 2005, 79th Leg., Ch. 727 (H.B. 2017), Sec. 4, eff. April 1, 2007.Amended by: Acts 2019, 86th Leg., R.S., Ch. 1218 (S.B. 1742), Sec. 3.02, eff. September 1, 2019.|
TX Ins Code § 4201.153 (2021)
2021 Texas Statutes|Insurance Code|Title 14 - Utilization Review and Independent Review|Chapter 4201 - Utilization Review Agents|Subchapter D. Utilization Review: General Standards|Section 4201.153. Screening Criteria and Review Procedures

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 (H.B. 2017), Sec. 4, eff. April 1, 2007.|
TX Ins Code § 4201.154 (2021)
2021 Texas Statutes|Insurance Code|Title 14 - Utilization Review and Independent Review|Chapter 4201 - Utilization Review Agents|Subchapter D. Utilization Review: General Standards|Section 4201.154. Review and Inspection of Screening Criteria and Review Procedures

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 (H.B. 2017), Sec. 4, eff. April 1, 2007.|
TX Ins Code § 4201.155 (2021)
2021 Texas Statutes|Insurance Code|Title 14 - Utilization Review and Independent Review|Chapter 4201 - Utilization Review Agents|Subchapter D. Utilization Review: General Standards|Section 4201.155. Limitation on Notice Requirements and Review Procedures

Sec. 4201.155.  LIMITATION ON NOTICE REQUIREMENTS AND REVIEW PROCEDURES.  (a)  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.(b)  This section may not be construed to release a health insurance policy or health benefit plan from full compliance with this chapter or other applicable law.|Added by Acts 2005, 79th Leg., Ch. 727 (H.B. 2017), Sec. 4, eff. April 1, 2007.Amended by: Acts 2019, 86th Leg., R.S., Ch. 1218 (S.B. 1742), Sec. 3.03, eff. September 1, 2019.|
TX Ins Code § 4201.201 (2021)
2021 Texas Statutes|Insurance Code|Title 14 - Utilization Review and Independent Review|Chapter 4201 - Utilization Review Agents|Subchapter E. Utilization Review: Relations With Patients and Health Care Providers|Section 4201.201. Repetitive Contacts With Health Care Provider or Patient; Frequency of Reviews

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 (H.B. 2017), Sec. 4, eff. April 1, 2007.|
TX Ins Code § 4201.202 (2021)
2021 Texas Statutes|Insurance Code|Title 14 - Utilization Review and Independent Review|Chapter 4201 - Utilization Review Agents|Subchapter E. Utilization Review: Relations With Patients and Health Care Providers|Section 4201.202. Observing or Participating in Patient's Care

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 (H.B. 2017), Sec. 4, eff. April 1, 2007.|
TX Ins Code § 4201.203 (2021)
2021 Texas Statutes|Insurance Code|Title 14 - Utilization Review and Independent Review|Chapter 4201 - Utilization Review Agents|Subchapter E. Utilization Review: Relations With Patients and Health Care Providers|Section 4201.203. Mental Health Therapy

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 (H.B. 2017), Sec. 4, eff. April 1, 2007.|
TX Ins Code § 4201.204 (2021)
2021 Texas Statutes|Insurance Code|Title 14 - Utilization Review and Independent Review|Chapter 4201 - Utilization Review Agents|Subchapter E. Utilization Review: Relations With Patients and Health Care Providers|Section 4201.204. Complaint System

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)  Repealed by Acts 2015, 84th Leg., R.S., Ch. 42 , Sec. 3.01(7), eff. September 1, 2015.(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 (H.B. 2017), Sec. 4, eff. April 1, 2007.Amended by: Acts 2015, 84th Leg., R.S., Ch. 42 (S.B. 784), Sec. 3.01(7), eff. September 1, 2015.|
TX Ins Code § 4201.205 (2021)
2021 Texas Statutes|Insurance Code|Title 14 - Utilization Review and Independent Review|Chapter 4201 - Utilization Review Agents|Subchapter E. Utilization Review: Relations With Patients and Health Care Providers|Section 4201.205. Designated Initial Contact

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 (H.B. 2017), Sec. 4, eff. April 1, 2007.|
TX Ins Code § 4201.206 (2021)
2021 Texas Statutes|Insurance Code|Title 14 - Utilization Review and Independent Review|Chapter 4201 - Utilization Review Agents|Subchapter E. Utilization Review: Relations With Patients and Health Care Providers|Section 4201.206. Opportunity to Discuss Treatment Before Adverse Determination

Sec. 4201.206.  OPPORTUNITY TO DISCUSS TREATMENT BEFORE ADVERSE DETERMINATION.  (a) Subject to Subsection (b) and the notice requirements of Subchapter G, before an adverse determination is issued by a utilization review agent who questions the medical necessity, the appropriateness, or the experimental or investigational nature of a health care service, the agent shall provide the health care provider who ordered, requested, provided, or is to provide the service a reasonable opportunity to discuss with a physician licensed to practice medicine in this state the patient's treatment plan and the clinical basis for the agent's determination.(b)  If the health care service described by Subsection (a) was ordered, requested, or provided, or is to be provided by a physician, the opportunity described by that subsection must be with a physician licensed to practice medicine in this state and who has the same or similar specialty as the physician.|Added by Acts 2005, 79th Leg., Ch. 727 (H.B. 2017), Sec. 4, eff. April 1, 2007.Amended by: Acts 2009, 81st Leg., R.S., Ch. 1330 (H.B. 4290), Sec. 9, eff. September 1, 2009.Acts 2019, 86th Leg., R.S., Ch. 1218 (S.B. 1742), Sec. 3.03, eff. September 1, 2019.Acts 2021, 87th Leg., R.S., Ch. 1018 (H.B. 3459), Sec. 4, eff. September 1, 2021.|
TX Ins Code § 4201.207 (2021)
2021 Texas Statutes|Insurance Code|Title 14 - Utilization Review and Independent Review|Chapter 4201 - Utilization Review Agents|Subchapter E. Utilization Review: Relations With Patients and Health Care Providers|Section 4201.207. Charges by Health Care Provider for Providing Medical Information

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 (H.B. 2017), Sec. 4, eff. April 1, 2007.Amended by: Acts 2007, 80th Leg., R.S., Ch. 134 (H.B. 1006), Sec. 8(a), eff. September 1, 2007.Acts 2007, 80th Leg., R.S., Ch. 730 (H.B. 2636), Sec. 3B.076(a), eff. September 1, 2007.Acts 2007, 80th Leg., R.S., Ch. 921 (H.B. 3167), Sec. 9.076(a), eff. September 1, 2007.|
TX Ins Code § 4201.251 (2021)
2021 Texas Statutes|Insurance Code|Title 14 - Utilization Review and Independent Review|Chapter 4201 - Utilization Review Agents|Subchapter F. Utilization Review: Personnel|Section 4201.251. Delegation of Utilization Review

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 or other applicable law, including the conduct of those to whom utilization review has been delegated.|Added by Acts 2005, 79th Leg., Ch. 727 (H.B. 2017), Sec. 4, eff. April 1, 2007.Amended by: Acts 2019, 86th Leg., R.S., Ch. 1218 (S.B. 1742), Sec. 3.03, eff. September 1, 2019.|
TX Ins Code § 4201.252 (2021)
2021 Texas Statutes|Insurance Code|Title 14 - Utilization Review and Independent Review|Chapter 4201 - Utilization Review Agents|Subchapter F. Utilization Review: Personnel|Section 4201.252. Personnel

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 and meet the requirements of this chapter and other applicable law, including applicable licensing requirements.(b)  Personnel, other than a physician licensed to practice medicine, 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 (H.B. 2017), Sec. 4, eff. April 1, 2007.Amended by: Acts 2019, 86th Leg., R.S., Ch. 1218 (S.B. 1742), Sec. 3.04, eff. September 1, 2019.|
TX Ins Code § 4201.253 (2021)
2021 Texas Statutes|Insurance Code|Title 14 - Utilization Review and Independent Review|Chapter 4201 - Utilization Review Agents|Subchapter F. Utilization Review: Personnel|Section 4201.253. Prohibited Bases for Employment, Compensation, Evaluations, or Performance Standards

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 (H.B. 2017), Sec. 4, eff. April 1, 2007.|
TX Ins Code § 4201.301 (2021)
2021 Texas Statutes|Insurance Code|Title 14 - Utilization Review and Independent Review|Chapter 4201 - Utilization Review Agents|Subchapter G. Notice of Determinations|Section 4201.301. General Duty to Notify

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 (H.B. 2017), Sec. 4, eff. April 1, 2007.|
TX Ins Code § 4201.302 (2021)
2021 Texas Statutes|Insurance Code|Title 14 - Utilization Review and Independent Review|Chapter 4201 - Utilization Review Agents|Subchapter G. Notice of Determinations|Section 4201.302. General Time for Notice

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 (H.B. 2017), Sec. 4, eff. April 1, 2007.|
TX Ins Code § 4201.303 (2021)
2021 Texas Statutes|Insurance Code|Title 14 - Utilization Review and Independent Review|Chapter 4201 - Utilization Review Agents|Subchapter G. Notice of Determinations|Section 4201.303. Adverse Determination: Contents of Notice

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.(c)  For an enrollee who is denied the provision of prescription drugs or intravenous infusions for which the patient is receiving benefits under the health insurance policy, 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 (H.B. 2017), Sec. 4, eff. April 1, 2007.Amended by: Acts 2015, 84th Leg., R.S., Ch. 1037 (H.B. 1621), Sec. 3, eff. September 1, 2015.|
TX Ins Code § 4201.304 (2021)
2021 Texas Statutes|Insurance Code|Title 14 - Utilization Review and Independent Review|Chapter 4201 - Utilization Review Agents|Subchapter G. Notice of Determinations|Section 4201.304. Time for Notice of Adverse Determination

Sec. 4201.304.  TIME FOR NOTICE OF ADVERSE DETERMINATION.  (a) Subject to Subsection (b), a utilization review agent shall provide notice of an adverse determination required by this subchapter as follows:(1)  with respect 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.(b)  A utilization review agent shall provide notice of an adverse determination for a concurrent review of the provision of prescription drugs or intravenous infusions for which the patient is receiving health benefits under the health insurance policy not later than the 30th day before the date on which the provision of prescription drugs or intravenous infusions will be discontinued.|Added by Acts 2005, 79th Leg., Ch. 727 (H.B. 2017), Sec. 4, eff. April 1, 2007.Amended by: Acts 2015, 84th Leg., R.S., Ch. 1037 (H.B. 1621), Sec. 4, eff. September 1, 2015.|