reglab/statecodes huggingface dataset:
2023 Texas Statutes › Insurance Code › Title 13 - Regulation of Professionals › Subtitle D - Other Professionals › Chapter 4152 - Reinsurance Intermediaries › Subchapter F. Requirements Relating to Insurers › Section 4152.252. Audited Statement of Manager's Financial Condition

Sec. 4152.252.  AUDITED STATEMENT OF MANAGER'S FINANCIAL CONDITION.  An insurer shall obtain annually an audited statement as provided by Section 4152.210 of the financial condition of each manager with whom the insurer transacts business.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 7, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 13 - Regulation of Professionals › Subtitle D - Other Professionals › Chapter 4152 - Reinsurance Intermediaries › Subchapter F. Requirements Relating to Insurers › Section 4152.253. Review of Underwriting and Claims Processing Operations

Sec. 4152.253.  REVIEW OF UNDERWRITING AND CLAIMS PROCESSING OPERATIONS.  An insurer shall conduct at least semiannually an on-site review of the underwriting and claims processing operations of a manager with whom the insurer enters into a contract under Section 4152.201.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 7, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 13 - Regulation of Professionals › Subtitle D - Other Professionals › Chapter 4152 - Reinsurance Intermediaries › Subchapter F. Requirements Relating to Insurers › Section 4152.254. Authority for Retrocessional Contracts or Participation in Reinsurance Syndicates

Sec. 4152.254.  AUTHORITY FOR RETROCESSIONAL CONTRACTS OR PARTICIPATION IN REINSURANCE SYNDICATES.  Binding authority for all retrocessional contracts or participation in reinsurance syndicates rests with an officer of the insurer.  That officer may not be affiliated with a manager acting for the insurer.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 7, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 13 - Regulation of Professionals › Subtitle D - Other Professionals › Chapter 4152 - Reinsurance Intermediaries › Subchapter F. Requirements Relating to Insurers › Section 4152.255. Notification of Termination of Manager's Contract

Sec. 4152.255.  NOTIFICATION OF TERMINATION OF MANAGER'S CONTRACT.  (a)  Not later than the 30th day after the date an insurer terminates a manager's contract, the insurer shall provide written notice to the commissioner of the termination, including the reasons for termination.
(b)  The notice is a privileged communication and is not subject to public disclosure or admission into evidence in any proceeding.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 7, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 13 - Regulation of Professionals › Subtitle D - Other Professionals › Chapter 4152 - Reinsurance Intermediaries › Subchapter F. Requirements Relating to Insurers › Section 4152.256. Appointment of Certain Persons to Board of Directors Prohibited

Sec. 4152.256.  APPOINTMENT OF CERTAIN PERSONS TO BOARD OF DIRECTORS PROHIBITED.  (a)  This section does not apply to a relationship governed by Chapter 823.
(b)  An insurer may not appoint to the insurer's board of directors an officer, director, employee, controlling shareholder, or submanager of a manager acting for that insurer.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 7, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 13 - Regulation of Professionals › Subtitle D - Other Professionals › Chapter 4152 - Reinsurance Intermediaries › Subchapter G. Discipline and Enforcement › Section 4152.301. Grounds for License Denial or Disciplinary Action

Sec. 4152.301.  GROUNDS FOR LICENSE DENIAL OR DISCIPLINARY ACTION.  The department may deny an application for a license or discipline a license holder under Subchapter C, Chapter 4005, if the department determines that the applicant or license holder, or a person who would be authorized to act on behalf of the applicant or license holder under Section 4152.057, has:
(1)  wilfully violated or participated in the violation of this chapter or another insurance law of this state;
(2)  intentionally made a material misstatement in the license application;
(3)  obtained or attempted to obtain the license by fraud or misrepresentation;
(4)  misappropriated, converted to the person's own use, or illegally withheld money required to be held in a fiduciary capacity;
(5)  materially misrepresented the terms or effect of any contract of insurance or reinsurance, or engaged in any fraudulent transaction;  or
(6)  been convicted of a felony or of a misdemeanor of which criminal fraud is an essential element.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 7, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 13 - Regulation of Professionals › Subtitle D - Other Professionals › Chapter 4152 - Reinsurance Intermediaries › Subchapter G. Discipline and Enforcement › Section 4152.302. Imposition of Sanctions

Sec. 4152.302.  IMPOSITION OF SANCTIONS.  (a)  The commissioner may impose or seek any sanction authorized by law, including the penalties authorized by Chapters 82 and 83, against a reinsurance intermediary, insurer, or reinsurer who the commissioner determines, after notice and hearing as provided by this code, has violated this chapter.
(b)  The commissioner may impose or seek any sanction authorized by law, including the penalties authorized by Chapter 101, against a nonlicensed reinsurance intermediary who violates this chapter.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 7, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 13 - Regulation of Professionals › Subtitle D - Other Professionals › Chapter 4153 - Risk Managers › Subchapter A. General Provisions › Section 4153.001. Definition

Sec. 4153.001.  DEFINITION.  In this chapter, "risk manager" means a person who:
(1)  represents to the public that the person is a risk manager;  and
(2)  for compensation examines or evaluates risks for and provides advice regarding reduction of risks to a person seeking to obtain or renew property and casualty insurance coverage in this state.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 7, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 13 - Regulation of Professionals › Subtitle D - Other Professionals › Chapter 4153 - Risk Managers › Subchapter A. General Provisions › Section 4153.002. Exemptions

Sec. 4153.002.  EXEMPTIONS.  This chapter does not apply to a person who is employed as a risk manager by:
(1)  a liability insurance company authorized to engage in business in this state;
(2)  a single employer;  or
(3)  a public self-insurance pool.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 7, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 13 - Regulation of Professionals › Subtitle D - Other Professionals › Chapter 4153 - Risk Managers › Subchapter A. General Provisions › Section 4153.003. Rules

Sec. 4153.003.  RULES.  The commissioner may adopt rules necessary to carry out this chapter and to regulate risk managers.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 7, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 13 - Regulation of Professionals › Subtitle D - Other Professionals › Chapter 4153 - Risk Managers › Subchapter B. License Requirements › Section 4153.051. License Required

Sec. 4153.051.  LICENSE REQUIRED.  A person may not act as or represent that the person is a risk manager in this state unless the person:
(1)  meets the requirements prescribed by this chapter and department rules;  and
(2)  holds a license issued by the department.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 7, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 13 - Regulation of Professionals › Subtitle D - Other Professionals › Chapter 4153 - Risk Managers › Subchapter B. License Requirements › Section 4153.052. Application

Sec. 4153.052.  APPLICATION.  (a)  To obtain a license to act as a risk manager in this state, an applicant must submit to the department an application on forms prescribed by the commissioner and provided by the department.
(b)  An application must be accompanied by the license fee required by Section 4153.057 and include:
(1)  information the department requires relating to the applicant's identity, personal history, experience, and business record;  and
(2)  any other information the department requires.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 7, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 13 - Regulation of Professionals › Subtitle D - Other Professionals › Chapter 4153 - Risk Managers › Subchapter B. License Requirements › Section 4153.053. Qualifications

Sec. 4153.053.  QUALIFICATIONS.  To qualify for a risk manager's license, an applicant must:
(1)  be at least 18 years of age;
(2)  maintain a place of business in this state;
(3)  meet the application requirements prescribed by this chapter and department rules;
(4)  take and pass the examination required by this chapter;  and
(5)  pay the examination and license fees.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 7, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 13 - Regulation of Professionals › Subtitle D - Other Professionals › Chapter 4153 - Risk Managers › Subchapter B. License Requirements › Section 4153.054. Examination

Sec. 4153.054.  EXAMINATION.  (a)  Except as provided by Sections 4153.055 and 4153.058, an applicant for a risk manager's license must personally take and pass an examination to the satisfaction of the commissioner under this chapter and department rules.
(b)  The commissioner shall prescribe the examination for a risk manager's license.  The examination must:
(1)  be designed to test the qualifications and competency of the applicant to be a risk manager;  and
(2)  be of sufficient scope to reasonably test the applicant's knowledge of risk management and the duties and responsibilities of a risk manager under the laws of this state and department rules.
(c)  The department shall:
(1)  determine the times and places for examinations;  and
(2)  give reasonable public notice of the examinations in the manner provided by department rules.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 7, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 13 - Regulation of Professionals › Subtitle D - Other Professionals › Chapter 4153 - Risk Managers › Subchapter B. License Requirements › Section 4153.055. Exemptions From Examination and Continuing Education Requirement

Sec. 4153.055.  EXEMPTIONS FROM EXAMINATION AND CONTINUING EDUCATION REQUIREMENT.  (a) An applicant is not required to take an examination to obtain a risk manager's license if the applicant holds the designation of:
(1)  chartered property casualty underwriter (CPCU) from the American Institute for Chartered Property Casualty Underwriters;
(2)  certified insurance counselor (CIC) from the national Society of Certified Insurance Counselors;
(3)  associate in risk management (ARM) from the Insurance Institute of America; or
(4)  Certified Risk Manager (CRM) from The National Alliance for Insurance Education & Research.
(b)  A license holder who has held a designation described by Subsection (a)(2), (3), or (4) for a period of not less than 30 years is exempt from continuing education requirements established under this title.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 7, eff. April 1, 2005.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 1172 (S.B. 876), Sec. 21, eff. September 1, 2015.
2023 Texas Statutes › Insurance Code › Title 13 - Regulation of Professionals › Subtitle D - Other Professionals › Chapter 4153 - Risk Managers › Subchapter B. License Requirements › Section 4153.056. Reexamination

Sec. 4153.056.  REEXAMINATION.  (a)  An applicant who fails the examination may retake the examination on payment of an additional examination fee.
(b)  The commissioner may require the applicant to wait for a reasonable period determined by the commissioner before the applicant may retake the examination.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 7, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 13 - Regulation of Professionals › Subtitle D - Other Professionals › Chapter 4153 - Risk Managers › Subchapter B. License Requirements › Section 4153.057. Fees

Sec. 4153.057.  FEES.  (a)  The commissioner shall set and collect in advance a nonrefundable fee, in an amount not to exceed $50, for:
(1)  an examination required by this chapter if the department administers the examination;
(2)  a risk manager's license;  and
(3)  the renewal of a risk manager's license.
(b)  A fee collected under this section shall be deposited to the credit of the Texas Department of Insurance operating account.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 7, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 13 - Regulation of Professionals › Subtitle D - Other Professionals › Chapter 4153 - Risk Managers › Subchapter B. License Requirements › Section 4153.058. Reciprocal License

Sec. 4153.058.  RECIPROCAL LICENSE.  On submission of an application and the license fee required by Section 4153.057, a person may receive a risk manager's license without examination if the person is licensed as a risk manager by another state, the licensing requirements of which were, on the date the license was issued, substantially equivalent to the requirements prescribed by this chapter.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 7, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 13 - Regulation of Professionals › Subtitle D - Other Professionals › Chapter 4153 - Risk Managers › Subchapter B. License Requirements › Section 4153.059. License Expiration

Sec. 4153.059.  LICENSE EXPIRATION.  Except as otherwise provided by a staggered renewal system adopted under Section 4003.002, a risk manager's license expires on the second anniversary of the date the license was issued.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 7, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 13 - Regulation of Professionals › Subtitle D - Other Professionals › Chapter 4153 - Risk Managers › Subchapter B. License Requirements › Section 4153.060. License Renewal

Sec. 4153.060.  LICENSE RENEWAL.  (a)  A license holder may renew an unexpired license by:
(1)  filing with the department a completed renewal application;  and
(2)  paying the nonrefundable renewal fee.
(b)  The commissioner shall issue a renewal certificate to the license holder if the commissioner determines the license holder continues to be eligible for the license.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 7, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 13 - Regulation of Professionals › Subtitle D - Other Professionals › Chapter 4153 - Risk Managers › Subchapter C. Powers and Duties of Risk Managers › Section 4153.101. Place of Business

Sec. 4153.101.  PLACE OF BUSINESS.  A license holder shall maintain a place of business in this state that is:
(1)  accessible to the public;  and
(2)  located at the place at which the license holder principally conducts business.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 7, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 13 - Regulation of Professionals › Subtitle D - Other Professionals › Chapter 4153 - Risk Managers › Subchapter C. Powers and Duties of Risk Managers › Section 4153.102. Notification of Change of Place of Business

Sec. 4153.102.  NOTIFICATION OF CHANGE OF PLACE OF BUSINESS.  A license holder who changes the address of the license holder's place of business from the address that appears on the license shall notify the department of that change as provided by department rules.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 7, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 13 - Regulation of Professionals › Subtitle D - Other Professionals › Chapter 4153 - Risk Managers › Subchapter D. Disciplinary Action › Section 4153.151. Grounds for Disciplinary Action

Sec. 4153.151.  GROUNDS FOR DISCIPLINARY ACTION.  The department may discipline a license holder or deny an applicant a license under Subchapter C, Chapter 4005:
(1)  for any cause for which, if known by the department, issuance of the license could have been refused;  or
(2)  if the license holder or applicant:
(A)  wilfully or knowingly violates this chapter, an insurance law of this state, or a department rule;
(B)  obtains or attempts to obtain a license through wilful misrepresentation or fraud;
(C)  fails the examination required by this chapter;  or
(D)  is convicted on final judgment of a felony.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 7, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 13 - Regulation of Professionals › Subtitle D - Other Professionals › Chapter 4153 - Risk Managers › Subchapter D. Disciplinary Action › Section 4153.152. License Suspension

Sec. 4153.152.  LICENSE SUSPENSION.  (a)  An order suspending a license must specify the duration of the suspension period.  The department may not suspend a license for a period of more than 12 months.
(b)  A license holder whose license is revoked or suspended shall surrender the license to the commissioner at the commissioner's request.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 7, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 13 - Regulation of Professionals › Subtitle D - Other Professionals › Chapter 4153 - Risk Managers › Subchapter D. Disciplinary Action › Section 4153.153. Reinstatement or Reissuance of License

Sec. 4153.153.  REINSTATEMENT OR REISSUANCE OF LICENSE.  The commissioner may not reinstate the license of or reissue a license to a person whose license is suspended or revoked or to whom the department refuses to issue a renewal certificate until the first anniversary of the date of the suspension, revocation, or refusal to renew.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 7, eff. April 1, 2005.
2023 Texas Statutes › Insurance Code › Title 14 - Utilization Review and Independent Review › Chapter 4201 - Utilization Review Agents › Subchapter A. General Provisions › Section 4201.001. Purpose

Sec. 4201.001.  PURPOSE.  The purpose of this chapter is to:
(1)  promote the delivery of quality health care in a cost-effective manner;
(2)  ensure that a utilization review agent adheres to reasonable standards for conducting utilization review;
(3)  foster greater coordination and cooperation between a health care provider and utilization review agent;
(4)  improve communications and knowledge of benefits among all parties concerned before an expense is incurred; and
(5)  ensure that a utilization review agent maintains the confidentiality of medical records in accordance with applicable law.
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 A. General Provisions › Section 4201.003. Rules

Sec. 4201.003.  RULES.  (a)  The commissioner may adopt rules to implement this chapter.
(b)  A rule adopted under this chapter relates only to a person or entity subject to this chapter.
(c)  Repealed by Acts 2011, 82nd Leg., R.S., Ch. 1147, Sec. 2.008(11), eff. September 1, 2011.
(d)  Repealed by Acts 2011, 82nd Leg., R.S., Ch. 1147, Sec. 2.008(11), eff. September 1, 2011.
Added by Acts 2005, 79th Leg., Ch. 727 (H.B. 2017), Sec. 4, eff. April 1, 2007.
Amended by:
Acts 2011, 82nd Leg., R.S., Ch. 1147 (H.B. 1951), Sec. 2.008(11), eff. September 1, 2011.
2023 Texas Statutes › Insurance Code › Title 14 - Utilization Review and Independent Review › Chapter 4201 - Utilization Review Agents › Subchapter A. General Provisions › Section 4201.004. Telephone Access

Sec. 4201.004.  TELEPHONE ACCESS.  (a)  A utilization review agent shall:
(1)  have appropriate personnel reasonably available, by toll-free telephone at least 40 hours per week during normal business hours in this state, to discuss patients' care and allow response to telephone review requests;
(2)  have a telephone system capable, during hours other than normal business hours, of accepting or recording incoming telephone calls or of providing instructions to a caller; and
(3)  respond to a call made during hours other than normal business hours not later than the second working day after the later of:
(A)  the date the call was received; or
(B)  the date the details necessary to respond have been received from the caller.
(b)  A utilization review agent must provide to the commissioner a written description of the procedures to be used when responding with respect to poststabilization care subsequent to emergency treatment as requested by a treating 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 B. Applicability of Chapter › Section 4201.051. Persons Providing Information About Scope of Coverage or Benefits

Sec. 4201.051.  PERSONS PROVIDING INFORMATION ABOUT SCOPE OF COVERAGE OR BENEFITS.  This chapter does not apply to a person who:
(1)  provides information to an enrollee about scope of coverage or benefits provided under a health insurance policy or health benefit plan; and
(2)  does not determine whether a particular health care service provided or to be provided to an enrollee is:
(A)  medically necessary or appropriate; or
(B)  experimental or investigational.
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. 8, eff. September 1, 2009.
2023 Texas Statutes › Insurance Code › Title 14 - Utilization Review and Independent Review › Chapter 4201 - Utilization Review Agents › Subchapter B. Applicability of Chapter › Section 4201.052. Certain Contracts With Federal Government

Sec. 4201.052.  CERTAIN CONTRACTS WITH FEDERAL GOVERNMENT.  This chapter does not apply to a contract with the federal government to provide utilization review with respect to a patient who is eligible for services under Title XVIII or XIX of the Social Security Act (42 U.S.C. Section 1395 et seq. or Section 1396 et seq.).
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 B. Applicability of Chapter › Section 4201.053. Medicaid and Other State Health or Mental Health Programs

Sec. 4201.053.  MEDICAID AND OTHER STATE HEALTH OR MENTAL HEALTH PROGRAMS. (a) Except as provided by Section 4201.057, this chapter does not apply to:
(1)  the state Medicaid program;
(2)  the services program for children with special health care needs under Chapter 35, Health and Safety Code;
(3)  a program administered under Title 2, Human Resources Code;
(4)  a program of the Department of State Health Services relating to mental health services;
(5)  a program of the Department of Aging and Disability Services relating to intellectual disability services; or
(6)  a program of the Texas Department of Criminal Justice.
Text of subsection effective until April 01, 2025
(b)  Sections 4201.303(c), 4201.304(b), 4201.357(a-1), and 4201.3601 do not apply to:
(1)  the child health program under Chapter 62, Health and Safety Code, or the health benefits plan for children under Chapter 63, Health and Safety Code;
(2)  the Employees Retirement System of Texas or another entity issuing or administering a coverage plan under Chapter 1551;
(3)  the Teacher Retirement System of Texas or another entity issuing or administering a plan under Chapter 1575 or 1579;
(4)  The Texas A&M University System or The University of Texas System or another entity issuing or administering coverage under Chapter 1601; and
(5)  a managed care organization providing a Medicaid managed care plan under Chapter 533, Government Code.
Text of subsection effective on April 01, 2025
(b)  Sections 4201.303(c), 4201.304(b), 4201.357(a-1), and 4201.3601 do not apply to:
(1)  the child health program under Chapter 62, Health and Safety Code, or the health benefits plan for children under Chapter 63, Health and Safety Code;
(2)  the Employees Retirement System of Texas or another entity issuing or administering a coverage plan under Chapter 1551;
(3)  the Teacher Retirement System of Texas or another entity issuing or administering a plan under Chapter 1575 or 1579;
(4)  The Texas A&M University System or The University of Texas System or another entity issuing or administering coverage under Chapter 1601; and
(5)  a managed care organization providing a Medicaid managed care plan under Chapter 540 or 540A, Government Code, as applicable.
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. 1, eff. September 1, 2015.
Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 2.139, eff. April 1, 2025.
2023 Texas Statutes › Insurance Code › Title 14 - Utilization Review and Independent Review › Chapter 4201 - Utilization Review Agents › Subchapter B. Applicability of Chapter › Section 4201.054. Workers' Compensation Benefits

Sec. 4201.054.  WORKERS' COMPENSATION BENEFITS.  (a)  Except as provided by this section, this chapter applies to utilization review of a health care service provided to a person eligible for workers' compensation medical benefits under Title 5, Labor Code. The commissioner of workers' compensation shall regulate as provided by this chapter a person who performs utilization review of a medical benefit provided under Title 5, Labor Code.
(b)  Sections 4201.303(c), 4201.304(b), 4201.357(a-1), and 4201.3601 do not apply to utilization review of a health care service provided to a person eligible for workers' compensation benefits under Title 5, Labor Code.
(c)  Title 5, Labor Code, prevails in the event of a conflict between this chapter and Title 5, Labor Code.
(d)  The commissioner of workers' compensation may adopt rules as necessary to implement this section.
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. 7(a), eff. September 1, 2007.
Acts 2007, 80th Leg., R.S., Ch. 134 (H.B. 1006), Sec. 7(b), eff. September 1, 2007.
Acts 2007, 80th Leg., R.S., Ch. 730 (H.B. 2636), Sec. 3B.075(a), eff. September 1, 2007.
Acts 2007, 80th Leg., R.S., Ch. 730 (H.B. 2636), Sec. 3B.075(b), eff. September 1, 2007.
Acts 2007, 80th Leg., R.S., Ch. 921 (H.B. 3167), Sec. 9.075(a), eff. September 1, 2007.
Acts 2007, 80th Leg., R.S., Ch. 921 (H.B. 3167), Sec. 9.075(b), eff. September 1, 2007.
Acts 2015, 84th Leg., R.S., Ch. 1037 (H.B. 1621), Sec. 2, eff. September 1, 2015.
2023 Texas Statutes › Insurance Code › Title 14 - Utilization Review and Independent Review › Chapter 4201 - Utilization Review Agents › Subchapter B. Applicability of Chapter › Section 4201.055. Health Care Service Provided Under Automobile Insurance Policy

Sec. 4201.055.  HEALTH CARE SERVICE PROVIDED UNDER AUTOMOBILE INSURANCE POLICY.  This chapter does not apply to utilization review of a health care service provided under an automobile insurance policy or contract that is authorized under Chapter 2301 or Article 5.13-2 or that is issued under Chapter 981.
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 B. Applicability of Chapter › Section 4201.056. Employee Welfare Benefit Plans

Sec. 4201.056.  EMPLOYEE WELFARE BENEFIT PLANS.  This chapter does not apply to the terms or benefits of an employee welfare benefit plan defined by Section 3(1) of the Employee Retirement Income Security Act of 1974 (29 U.S.C. Section 1002(1)).
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 B. Applicability of Chapter › Section 4201.057. Health Maintenance Organizations

Sec. 4201.057.  HEALTH MAINTENANCE ORGANIZATIONS.  (a)  In this section, "health maintenance organization" includes a health maintenance organization that contracts with the Health and Human Services Commission or with an agency operating part of the state Medicaid managed care program to provide health care services to recipients of medical assistance under Chapter 32, Human Resources Code.
(b)  This chapter applies to a health maintenance organization except as expressly provided by this section.
(c)  As a condition of holding a certificate of authority to engage in the business of a health maintenance organization, a health maintenance organization that performs utilization review must:
(1)  comply with this chapter, except Subchapter C; and
(2)  submit to assessment of a maintenance tax under Chapter 258 to cover the costs of administering compliance with this subsection.
(d)  The commissioner shall adopt rules for appropriate verification and enforcement of compliance with Subsection (c).
(e)  Notwithstanding Subsection (c)(1), a health maintenance organization that performs utilization review for a person or entity subject to this chapter, other than a person or entity for which the health maintenance organization is the payor, must obtain a certificate of registration under Subchapter C and shall comply with all of the provisions of this chapter.
(f)  This chapter does not prohibit or limit the distribution of a portion of the savings from the reduction or elimination of unnecessary medical services, treatment, supplies, confinements, or days of confinement in a health care facility through profit sharing, bonus, or withholding arrangements to a participating physician or participating health care provider for providing health care services to an enrollee.
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 B. Applicability of Chapter › Section 4201.058. Insurers

Sec. 4201.058.  INSURERS.  (a)  This chapter applies to an insurer subject to this code that delivers or issues for delivery a health insurance policy in this state except as expressly provided by this section.  As a condition of holding a certificate of authority to engage in the business of insurance, an insurer that performs utilization review shall comply with this chapter, except Subchapter C.  The insurer is subject to assessment of a maintenance tax under Chapter 257 to cover the costs of administering compliance with this subsection.
(b)  The commissioner shall adopt rules for appropriate verification and enforcement of compliance with Subsection (a).
(c)  Notwithstanding Subsection (a), an insurer subject to this code that performs utilization review for a person or entity subject to this chapter, other than a person or entity for which the insurer is the payor, must obtain a certificate of registration under Subchapter C and shall comply with all of the provisions of 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 C. Certification › Section 4201.101. Certificate of Registration Required

Sec. 4201.101.  CERTIFICATE OF REGISTRATION REQUIRED.  A utilization review agent may not conduct utilization review unless the commissioner issues a certificate of registration to the agent 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 C. Certification › Section 4201.102. Requirements for Certification

Sec. 4201.102.  REQUIREMENTS FOR CERTIFICATION.  (a)  The commissioner may issue a certificate of registration only to an applicant who has met all the requirements of this chapter and all applicable rules adopted by the commissioner.
(b)  As a condition of holding a certificate of registration or renewal of a certificate, a utilization review agent must maintain compliance with Subchapters D, E, and F.
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 C. Certification › Section 4201.103. Certificate Renewal

Sec. 4201.103.  CERTIFICATE RENEWAL.  Certification may be renewed biennially by filing, not later than March 1, a renewal form with the commissioner accompanied by a fee in an amount set by the commissioner.
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 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
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 4201.201. 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.
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 4201.202. 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.
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 4201.203. 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.
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 4201.204. 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.
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 4201.205. 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.
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 4201.206. 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.