reglab/housing_qa huggingface dataset:
TX Ins Code § 4201.351 (2021)
2021 Texas Statutes|Insurance Code|Title 14 - Utilization Review and Independent Review|Chapter 4201 - Utilization Review Agents|Subchapter H. Appeal of Adverse Determination|Section 4201.351. Complaint as Appeal

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 (H.B. 2017), Sec. 4, eff. April 1, 2007.|
TX Ins Code § 4201.352 (2021)
2021 Texas Statutes|Insurance Code|Title 14 - Utilization Review and Independent Review|Chapter 4201 - Utilization Review Agents|Subchapter H. Appeal of Adverse Determination|Section 4201.352. Written Description of Appeal Procedures

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 (H.B. 2017), Sec. 4, eff. April 1, 2007.|
TX Ins Code § 4201.353 (2021)
2021 Texas Statutes|Insurance Code|Title 14 - Utilization Review and Independent Review|Chapter 4201 - Utilization Review Agents|Subchapter H. Appeal of Adverse Determination|Section 4201.353. Appeal Procedures Must Be Reasonable

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 (H.B. 2017), Sec. 4, eff. April 1, 2007.|
TX Ins Code § 4201.354 (2021)
2021 Texas Statutes|Insurance Code|Title 14 - Utilization Review and Independent Review|Chapter 4201 - Utilization Review Agents|Subchapter H. Appeal of Adverse Determination|Section 4201.354. Persons or Entities Who May Appeal

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 (H.B. 2017), Sec. 4, eff. April 1, 2007.|
TX Ins Code § 4201.355 (2021)
2021 Texas Statutes|Insurance Code|Title 14 - Utilization Review and Independent Review|Chapter 4201 - Utilization Review Agents|Subchapter H. Appeal of Adverse Determination|Section 4201.355. Acknowledgment of Appeal

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 (H.B. 2017), Sec. 4, eff. April 1, 2007.|
TX Ins Code § 4201.356 (2021)
2021 Texas Statutes|Insurance Code|Title 14 - Utilization Review and Independent Review|Chapter 4201 - Utilization Review Agents|Subchapter H. Appeal of Adverse Determination|Section 4201.356. Decision by Physician Required; Specialty Review

Sec. 4201.356.  DECISION BY PHYSICIAN REQUIRED; SPECIALTY REVIEW.  (a)  The procedures for appealing an adverse determination must provide that a physician licensed to practice medicine 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 requested or denied the enrollee's health care provider requests 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 denial or 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 (H.B. 2017), Sec. 4, eff. April 1, 2007.Amended by: Acts 2019, 86th Leg., R.S., Ch. 1218 (S.B. 1742), Sec. 3.05, eff. September 1, 2019.|
TX Ins Code § 4201.357 (2021)
2021 Texas Statutes|Insurance Code|Title 14 - Utilization Review and Independent Review|Chapter 4201 - Utilization Review Agents|Subchapter H. Appeal of Adverse Determination|Section 4201.357. Expedited Appeal for Denial of Emergency Care, Continued Hospitalization, Prescription Drugs or Intravenous Infusions

Sec. 4201.357.  EXPEDITED APPEAL FOR DENIAL OF EMERGENCY CARE, CONTINUED HOSPITALIZATION, PRESCRIPTION DRUGS OR INTRAVENOUS INFUSIONS.  (a)  The procedures for appealing an adverse determination must include, in addition to the written appeal, a procedure for an expedited appeal of a denial of emergency care, a denial of continued hospitalization, or a denial of another service if the requesting health care provider includes a written statement with supporting documentation that the service is necessary to treat a life-threatening condition or prevent serious harm to the patient.  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.(a-1)  The procedures for appealing an adverse determination must include, in addition to the written appeal and the appeal described by Subsection (a), a procedure for an expedited appeal of a denial of prescription drugs or intravenous infusions for which the patient is receiving benefits under the health insurance policy.  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.(a-2)  An adverse determination under Section 1369.0546 is entitled to an expedited appeal.  The physician or, if appropriate, other health care provider deciding the appeal must consider atypical diagnoses and the needs of atypical patient populations.(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 (H.B. 2017), Sec. 4, eff. April 1, 2007.Amended by: Acts 2015, 84th Leg., R.S., Ch. 1037 (H.B. 1621), Sec. 5, eff. September 1, 2015.Acts 2015, 84th Leg., R.S., Ch. 1037 (H.B. 1621), Sec. 6, eff. September 1, 2015.Acts 2017, 85th Leg., R.S., Ch. 103 (S.B. 680), Sec. 3, eff. September 1, 2017.Acts 2019, 86th Leg., R.S., Ch. 1218 (S.B. 1742), Sec. 3.06, eff. September 1, 2019.|
TX Ins Code § 4201.358 (2021)
2021 Texas Statutes|Insurance Code|Title 14 - Utilization Review and Independent Review|Chapter 4201 - Utilization Review Agents|Subchapter H. Appeal of Adverse Determination|Section 4201.358. Response Letter to Interested Persons

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 (H.B. 2017), Sec. 4, eff. April 1, 2007.|
TX Ins Code § 4201.359 (2021)
2021 Texas Statutes|Insurance Code|Title 14 - Utilization Review and Independent Review|Chapter 4201 - Utilization Review Agents|Subchapter H. Appeal of Adverse Determination|Section 4201.359. Notice of Appeal

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 (H.B. 2017), Sec. 4, eff. April 1, 2007.|
TX Ins Code § 4201.360 (2021)
2021 Texas Statutes|Insurance Code|Title 14 - Utilization Review and Independent Review|Chapter 4201 - Utilization Review Agents|Subchapter H. Appeal of Adverse Determination|Section 4201.360. Immediate Appeal to Independent Review Organization in Life-Threatening Circumstances

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 (H.B. 2017), Sec. 4, eff. April 1, 2007.|
TX Ins Code § 4201.3601 (2021)
2021 Texas Statutes|Insurance Code|Title 14 - Utilization Review and Independent Review|Chapter 4201 - Utilization Review Agents|Subchapter H. Appeal of Adverse Determination|Section 4201.3601. Immediate Appeal to Independent Review Organization for Denial of Prescription Drugs or Intravenous Infusions

Sec. 4201.3601.  IMMEDIATE APPEAL TO INDEPENDENT REVIEW ORGANIZATION FOR DENIAL OF PRESCRIPTION DRUGS OR INTRAVENOUS INFUSIONS.  Notwithstanding any other law, in a circumstance involving the provision of prescription drugs or intravenous infusions for which the patient is receiving benefits under the health insurance policy, 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 2015, 84th Leg., R.S., Ch. 1037 (H.B. 1621), Sec. 7, eff. September 1, 2015.|
TX Ins Code § 4201.401 (2021)
2021 Texas Statutes|Insurance Code|Title 14 - Utilization Review and Independent Review|Chapter 4201 - Utilization Review Agents|Subchapter I. Independent Review of Adverse Determination|Section 4201.401. Review by Independent Review Organization; Compliance With Independent 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 (H.B. 2017), Sec. 4, eff. April 1, 2007.Amended by: Acts 2009, 81st Leg., R.S., Ch. 1330 (H.B. 4290), Sec. 11, eff. September 1, 2009.|
TX Ins Code § 4201.402 (2021)
2021 Texas Statutes|Insurance Code|Title 14 - Utilization Review and Independent Review|Chapter 4201 - Utilization Review Agents|Subchapter I. Independent Review of Adverse Determination|Section 4201.402. Information Provided to Independent Review Organization

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 (H.B. 2017), Sec. 4, eff. April 1, 2007.|
TX Ins Code § 4201.403 (2021)
2021 Texas Statutes|Insurance Code|Title 14 - Utilization Review and Independent Review|Chapter 4201 - Utilization Review Agents|Subchapter I. Independent Review of Adverse Determination|Section 4201.403. Payment for Independent Review

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 (H.B. 2017), Sec. 4, eff. April 1, 2007.|
TX Ins Code § 4201.451 (2021)
2021 Texas Statutes|Insurance Code|Title 14 - Utilization Review and Independent Review|Chapter 4201 - Utilization Review Agents|Subchapter J. Specialty Utilization Review Agents|Section 4201.451. Definition

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 (H.B. 2017), Sec. 4, eff. April 1, 2007.|
TX Ins Code § 4201.452 (2021)
2021 Texas Statutes|Insurance Code|Title 14 - Utilization Review and Independent Review|Chapter 4201 - Utilization Review Agents|Subchapter J. Specialty Utilization Review Agents|Section 4201.452. Inapplicability of Certain Other Law

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 (H.B. 2017), Sec. 4, eff. April 1, 2007.|
TX Ins Code § 4201.453 (2021)
2021 Texas Statutes|Insurance Code|Title 14 - Utilization Review and Independent Review|Chapter 4201 - Utilization Review Agents|Subchapter J. Specialty Utilization Review Agents|Section 4201.453. Utilization Review Plan

Sec. 4201.453.  UTILIZATION REVIEW PLAN.  A specialty utilization review agent's utilization review plan, including reconsideration and appeal requirements, must be:(1)  reviewed by a health care provider of the appropriate specialty who is licensed or otherwise authorized to provide the specialty health care service in this state; and(2)  conducted in accordance with standards developed with input from a health care provider of the appropriate specialty who is licensed or otherwise authorized to provide the specialty health care service 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. 3.07, eff. September 1, 2019.|
TX Ins Code § 4201.454 (2021)
2021 Texas Statutes|Insurance Code|Title 14 - Utilization Review and Independent Review|Chapter 4201 - Utilization Review Agents|Subchapter J. Specialty Utilization Review Agents|Section 4201.454. Utilization Review Under Direction of Provider of Same Specialty

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 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. 3.07, eff. September 1, 2019.|
TX Ins Code § 4201.455 (2021)
2021 Texas Statutes|Insurance Code|Title 14 - Utilization Review and Independent Review|Chapter 4201 - Utilization Review Agents|Subchapter J. Specialty Utilization Review Agents|Section 4201.455. Personnel

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 and meet the requirements of this chapter and other applicable law of this state, including applicable licensing laws.(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 (H.B. 2017), Sec. 4, eff. April 1, 2007.Amended by: Acts 2019, 86th Leg., R.S., Ch. 1218 (S.B. 1742), Sec. 3.08, eff. September 1, 2019.|
TX Ins Code § 4201.456 (2021)
2021 Texas Statutes|Insurance Code|Title 14 - Utilization Review and Independent Review|Chapter 4201 - Utilization Review Agents|Subchapter J. Specialty Utilization Review Agents|Section 4201.456. Opportunity to Discuss Treatment Before Adverse Determination

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, the appropriateness, or the experimental or investigational nature of a health care service, the agent shall provide the health care provider who ordered, requested, or is to provide 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 (H.B. 2017), Sec. 4, eff. April 1, 2007.Amended by: Acts 2009, 81st Leg., R.S., Ch. 1330 (H.B. 4290), Sec. 12, eff. September 1, 2009.Acts 2019, 86th Leg., R.S., Ch. 1218 (S.B. 1742), Sec. 3.09, eff. September 1, 2019.|
TX Ins Code § 4201.457 (2021)
2021 Texas Statutes|Insurance Code|Title 14 - Utilization Review and Independent Review|Chapter 4201 - Utilization Review Agents|Subchapter J. Specialty Utilization Review Agents|Section 4201.457. Appeal Decisions

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 (H.B. 2017), Sec. 4, eff. April 1, 2007.|
TX Ins Code § 4201.551 (2021)
2021 Texas Statutes|Insurance Code|Title 14 - Utilization Review and Independent Review|Chapter 4201 - Utilization Review Agents|Subchapter L. Confidentiality of Information; Access to Other Information|Section 4201.551. General Confidentiality Requirement

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 (H.B. 2017), Sec. 4, eff. April 1, 2007.|
TX Ins Code § 4201.552 (2021)
2021 Texas Statutes|Insurance Code|Title 14 - Utilization Review and Independent Review|Chapter 4201 - Utilization Review Agents|Subchapter L. Confidentiality of Information; Access to Other Information|Section 4201.552. Consent Requirements

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 (H.B. 2017), Sec. 4, eff. April 1, 2007.|
TX Ins Code § 4201.553 (2021)
2021 Texas Statutes|Insurance Code|Title 14 - Utilization Review and Independent Review|Chapter 4201 - Utilization Review Agents|Subchapter L. Confidentiality of Information; Access to Other Information|Section 4201.553. Providing Information to Affiliated Entities

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 (H.B. 2017), Sec. 4, eff. April 1, 2007.|
TX Ins Code § 4201.554 (2021)
2021 Texas Statutes|Insurance Code|Title 14 - Utilization Review and Independent Review|Chapter 4201 - Utilization Review Agents|Subchapter L. Confidentiality of Information; Access to Other Information|Section 4201.554. Providing Information to Commissioner

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 (H.B. 2017), Sec. 4, eff. April 1, 2007.|