2023 Texas Statutes › Insurance Code › Title 14 - Utilization Review and Independent Review › Chapter 4201 - Utilization Review Agents › Subchapter G. Notice of Determinations › Section 4201.305. Notice of Adverse Determination for Retrospective Utilization Review

Sec. 4201.305.  NOTICE OF ADVERSE DETERMINATION FOR RETROSPECTIVE UTILIZATION REVIEW.  (a)  Notwithstanding Sections 4201.302 and 4201.304, if a retrospective utilization review is conducted, the utilization review agent shall provide notice of an adverse determination under the retrospective utilization review in writing to the provider of record and the patient within a reasonable period, but not later than 30 days after the date on which the claim is received.
(b)  The period under Subsection (a) may be extended once  by the utilization review agent for a period not to exceed 15 days, if the utilization review agent:
(1)  determines that an extension is necessary due to matters beyond the utilization review agent's control; and
(2)  notifies the provider of record and the patient before the expiration of the initial 30-day period of the circumstances requiring the extension and the date by which the utilization review agent expects to make a determination.
(c)  If the extension under Subsection (b) is required because of the failure of the provider of record or the patient to submit information necessary to reach a determination on the request, the notice of extension must:
(1)  specifically describe the required information necessary to complete the request; and
(2)  give the provider of record and the patient at least 45 days from the date of receipt of the notice of extension to provide the specified information.
(d)  If the period for making the determination under this section is extended because of the failure of the provider of record or the patient to submit the information necessary to make the determination, the period for making the determination is tolled from the date on which the utilization review agent sends the notification of the extension to the provider of record or the patient until the earlier of:
(1)  the date on which the provider of record or the patient responds to the request for additional information; or
(2)  the date by which the specified information was to have been submitted.
(e)  If the periods for retrospective utilization review provided by this section conflict with the time limits concerning or related to payment of claims established under Subchapter J, Chapter 843, the time limits established under Subchapter J, Chapter 843, control.
(f)  If the periods for retrospective utilization review provided by this section conflict with the time limits concerning or related to payment of claims established under Subchapters C and C-1, Chapter 1301, the time limits established under Subchapters C and C-1, Chapter 1301, control.
(g)  If the periods for retrospective utilization review provided by this section conflict with the time limits concerning or related to payment of claims established under Section 408.027, Labor Code, the time limits established under Section 408.027, Labor Code, control.
Added by Acts 2009, 81st Leg., R.S., Ch. 1330 (H.B. 4290), Sec. 10, eff. September 1, 2009.