reglab/statecodes huggingface dataset:
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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 4201.555. Access to Recorded Personal Information

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 (H.B. 2017), Sec. 4, eff. April 1, 2007.
2023 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 4201.556. Publishing Information Identifiable to Health Care Provider

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 (H.B. 2017), Sec. 4, eff. April 1, 2007.
2023 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 4201.557. Requirement to Maintain Data in Confidential Manner

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 (H.B. 2017), Sec. 4, eff. April 1, 2007.
2023 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 4201.558. Destruction of Certain Confidential Documents

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 (H.B. 2017), Sec. 4, eff. April 1, 2007.
2023 Texas Statutes › Insurance Code › Title 14 - Utilization Review and Independent Review › Chapter 4201 - Utilization Review Agents › Subchapter M. Enforcement › Section 4201.601. Notice of Suspected Violation; Compelling Production of Information

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 (H.B. 2017), Sec. 4, eff. April 1, 2007.
2023 Texas Statutes › Insurance Code › Title 14 - Utilization Review and Independent Review › Chapter 4201 - Utilization Review Agents › Subchapter M. Enforcement › Section 4201.602. Enforcement Proceeding

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 (H.B. 2017), Sec. 4, eff. April 1, 2007.
2023 Texas Statutes › Insurance Code › Title 14 - Utilization Review and Independent Review › Chapter 4201 - Utilization Review Agents › Subchapter M. Enforcement › Section 4201.603. Remedies and Penalties for Violation

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 (H.B. 2017), Sec. 4, eff. April 1, 2007.
2023 Texas Statutes › Insurance Code › Title 14 - Utilization Review and Independent Review › Chapter 4201 - Utilization Review Agents › Subchapter N. Exemption From Preauthorization Requirements for Physicians and Providers Providing Certain Health Care Services › Section 4201.651. Definitions

Sec. 4201.651.  DEFINITIONS.  (a)  In this subchapter, "preauthorization" means a determination by a health maintenance organization, insurer, or person contracting with a health maintenance organization or insurer that health care services proposed to be provided to a patient are medically necessary and appropriate.
(b)  In this subchapter, terms defined by Section 843.002, including "health care services," "physician," and "provider," have the meanings assigned by that section.
Added by Acts 2021, 87th Leg., R.S., Ch. 1018 (H.B. 3459), Sec. 5, eff. September 1, 2021.
2023 Texas Statutes › Insurance Code › Title 14 - Utilization Review and Independent Review › Chapter 4201 - Utilization Review Agents › Subchapter N. Exemption From Preauthorization Requirements for Physicians and Providers Providing Certain Health Care Services › Section 4201.652. Applicability of Subchapter

Text of section effective until April 01, 2025
Sec. 4201.652.  APPLICABILITY OF SUBCHAPTER.  This subchapter applies only to:
(1)  a health benefit plan offered by a health maintenance organization operating under Chapter 843, except that this subchapter does not apply to:
(A)  the child health plan program under Chapter 62, Health and Safety Code, or the health benefits plan for children under Chapter 63, Health and Safety Code; or
(B)  the state Medicaid program, including the Medicaid managed care program operated under Chapter 533, Government Code;
(2)  a preferred provider benefit plan or exclusive provider benefit plan offered by an insurer under Chapter 1301; and
(3)  a person who contracts with a health maintenance organization or insurer to issue preauthorization determinations or perform the functions described in this subchapter for a health benefit plan to which this subchapter applies.
Added by Acts 2021, 87th Leg., R.S., Ch. 1018 (H.B. 3459), Sec. 5, eff. September 1, 2021.
Amended by:
Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 2.140, eff. April 1, 2025.
2023 Texas Statutes › Insurance Code › Title 14 - Utilization Review and Independent Review › Chapter 4201 - Utilization Review Agents › Subchapter N. Exemption From Preauthorization Requirements for Physicians and Providers Providing Certain Health Care Services › Section 4201.652. Applicability of Subchapter

Text of section effective on April 01, 2025
Sec. 4201.652.  APPLICABILITY OF SUBCHAPTER.  This subchapter applies only to:
(1)  a health benefit plan offered by a health maintenance organization operating under Chapter 843, except that this subchapter does not apply to:
(A)  the child health plan program under Chapter 62, Health and Safety Code, or the health benefits plan for children under Chapter 63, Health and Safety Code; or
(B)  the state Medicaid program, including the Medicaid managed care program operated under Chapter 540 or 540A, Government Code, as applicable;
(2)  a preferred provider benefit plan or exclusive provider benefit plan offered by an insurer under Chapter 1301; and
(3)  a person who contracts with a health maintenance organization or insurer to issue preauthorization determinations or perform the functions described in this subchapter for a health benefit plan to which this subchapter applies.
Added by Acts 2021, 87th Leg., R.S., Ch. 1018 (H.B. 3459), Sec. 5, eff. September 1, 2021.
Amended by:
Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 2.140, eff. April 1, 2025.
2023 Texas Statutes › Insurance Code › Title 14 - Utilization Review and Independent Review › Chapter 4201 - Utilization Review Agents › Subchapter N. Exemption From Preauthorization Requirements for Physicians and Providers Providing Certain Health Care Services › Section 4201.653. Exemption From Preauthorization Requirements for Physicians and Providers Providing Certain Health Care Services

Sec. 4201.653.  EXEMPTION FROM PREAUTHORIZATION REQUIREMENTS FOR PHYSICIANS AND PROVIDERS PROVIDING CERTAIN HEALTH CARE SERVICES.  (a)  A health maintenance organization or an insurer that uses a preauthorization process for health care services may not require a physician or provider to obtain preauthorization for a particular health care service if, in the most recent six-month evaluation period, as described by Subsection (b), the health maintenance organization or insurer has approved or would have approved not less than 90 percent of the preauthorization requests submitted by the physician or provider for the particular health care service.
(b)  Except as provided by Subsection (c), a health maintenance organization or insurer shall evaluate whether a physician or provider qualifies for an exemption from preauthorization requirements under Subsection (a) once every six months.
(c)  A health maintenance organization or insurer may continue an exemption under Subsection (a) without evaluating whether the physician or provider qualifies for the exemption under Subsection (a) for a particular evaluation period.
(d)  A physician or provider is not required to request an exemption under Subsection (a) to qualify for the exemption.
Added by Acts 2021, 87th Leg., R.S., Ch. 1018 (H.B. 3459), Sec. 5, eff. September 1, 2021.
2023 Texas Statutes › Insurance Code › Title 14 - Utilization Review and Independent Review › Chapter 4201 - Utilization Review Agents › Subchapter N. Exemption From Preauthorization Requirements for Physicians and Providers Providing Certain Health Care Services › Section 4201.654. Duration of Preauthorization Exemption

Sec. 4201.654.  DURATION OF PREAUTHORIZATION EXEMPTION.  (a)  A physician's or provider's exemption from preauthorization requirements under Section 4201.653 remains in effect until:
(1)  the 30th day after the date the health maintenance organization or insurer notifies the physician or provider of the health maintenance organization's or insurer's determination to rescind the exemption under Section 4201.655, if the physician or provider does not appeal the health maintenance organization's or insurer's determination; or
(2)  if the physician or provider appeals the determination, the fifth  day after the date the independent review organization affirms the health maintenance organization's or insurer's determination to rescind the exemption.
(b)  If a health maintenance organization or insurer does not finalize a rescission determination as specified in Subsection (a), then the physician or provider is considered to have met the criteria under Section 4201.653 to continue to qualify for the exemption.
Added by Acts 2021, 87th Leg., R.S., Ch. 1018 (H.B. 3459), Sec. 5, eff. September 1, 2021.
2023 Texas Statutes › Insurance Code › Title 14 - Utilization Review and Independent Review › Chapter 4201 - Utilization Review Agents › Subchapter N. Exemption From Preauthorization Requirements for Physicians and Providers Providing Certain Health Care Services › Section 4201.655. Denial or Rescission of Preauthorization Exemption

Sec. 4201.655.  DENIAL OR RESCISSION OF PREAUTHORIZATION EXEMPTION.  (a)  A health maintenance organization or insurer may rescind an exemption from preauthorization requirements under Section 4201.653 only:
(1)  during January or June of each  year;
(2)  if the health maintenance organization or insurer makes a determination, on the basis of a retrospective review of a random sample of not fewer than five and no more than 20 claims submitted by the physician or provider during the most recent evaluation period described by Section 4201.653(b), that less than 90 percent of the claims for the particular health care service met the medical necessity criteria that would have been used by the health maintenance organization or insurer when conducting preauthorization review for the particular health care service during the relevant evaluation period; and
(3)  if the health maintenance organization or insurer complies with other applicable requirements specified in this section, including:
(A)  notifying the physician or provider not less than 25 days before the proposed rescission is to take effect; and
(B)  providing with the notice under Paragraph (A):
(i)  the sample information used to make the determination under Subdivision (2); and
(ii)  a plain language explanation of how the physician or provider may appeal and seek an independent review of the determination.
(b)  A determination made under Subsection (a)(2) must be made by an individual licensed to practice medicine in this state.  For a determination made under Subsection (a)(2) with respect to a physician, the determination must be made by an individual licensed to practice medicine in this state who has the same or similar specialty as that physician.
(c)  A health maintenance organization or insurer may deny an exemption from preauthorization requirements under Section 4201.653 only if:
(1)  the physician or provider does not have the exemption at the time of the relevant evaluation period; and
(2)  the health maintenance organization or insurer provides the physician or provider with actual statistics and data for the relevant preauthorization request evaluation period and detailed information sufficient to demonstrate that the physician or provider does not meet the criteria for an exemption from preauthorization requirements for the particular health care service under Section 4201.653.
Added by Acts 2021, 87th Leg., R.S., Ch. 1018 (H.B. 3459), Sec. 5, eff. September 1, 2021.