reglab/statecodes huggingface dataset:
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 19 - LICENSING AND REGULATION OF INSURANCE PROFESSIONALS › Subchapter R - UTILIZATION REVIEWS FOR HEALTH CARE PROVIDED UNDER A HEALTH BENEFIT PLAN OR HEALTH INSURANCE POLICY › Division 1 - UTILIZATION REVIEWS › Section 19.1701 - General Provisions

Current through Reg. 49, No. 28; July 12, 2024
(a) Statutory
					 basis. This subchapter implements Insurance Code Chapter 4201, concerning
					 Utilization Review Agents.
(b)
					 Severability. If a court of competent jurisdiction holds that any provision of
					 this subchapter or its application to any person or circumstance is invalid for
					 any reason, the invalidity does not affect other provisions or applications of
					 this subchapter that can be given effect without the invalid provision or
					 application, and to this end the provisions of this subchapter are
					 severable.
(c) Purpose. The purpose
					 of this subchapter is to:
(1) promote the
					 delivery of quality health care in a cost-effective manner, including
					 protection of enrollee safety;
(2)
					 ensure that URAs adhere to reasonable standards for conducting utilization
					 reviews;
(3) foster greater
					 coordination and cooperation between health care providers and URAs;
(4) improve communications and knowledge of
					 medical benefits among all parties concerned before expenses are incurred;
					 and
(5) ensure that URAs maintain
					 the confidentiality of medical records in accord with applicable law.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 19 - LICENSING AND REGULATION OF INSURANCE PROFESSIONALS › Subchapter R - UTILIZATION REVIEWS FOR HEALTH CARE PROVIDED UNDER A HEALTH BENEFIT PLAN OR HEALTH INSURANCE POLICY › Division 1 - UTILIZATION REVIEWS › Section 19.1702 - Applicability

Current through Reg. 49, No. 28; July 12, 2024
(a) Limitations on applicability. Except as
					 provided in Insurance Code Chapter 4201, this subchapter applies to utilization
					 review performed under a health benefit plan or a health insurance policy.
(1) This subchapter does not apply to
					 utilization review performed under workers' compensation insurance
					 coverage.
(2) This subchapter does
					 not apply to a person who provides information to an enrollee; an individual
					 acting on behalf of an enrollee; or an enrollee's physician, doctor, or other
					 health care provider about scope of coverage or benefits, and does not
					 determine the medical necessity, appropriateness, or the experimental or
					 investigational nature of health care services.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 19 - LICENSING AND REGULATION OF INSURANCE PROFESSIONALS › Subchapter R - UTILIZATION REVIEWS FOR HEALTH CARE PROVIDED UNDER A HEALTH BENEFIT PLAN OR HEALTH INSURANCE POLICY › Division 1 - UTILIZATION REVIEWS › Section 19.1704 - Certification or Registration of URAs

Current through Reg. 49, No. 28; July 12, 2024
(a)
					 Applicability of certification or registration requirements. A person acting as
					 or holding itself out as a URA under this subchapter must be certified or
					 registered, as applicable, under Insurance Code §
											4201.057, concerning
					 Health Maintenance Organizations; Insurance Code §
											4201.058, concerning
					 Insurers; or Insurance Code §
											4201.101, concerning
					 Certificate of Registration Required, and this subchapter.
(1) If an insurance carrier or HMO performs
					 utilization review for an individual or entity subject to this subchapter for
					 which it is not the payor, the insurance carrier or HMO must be
					 certified.
(2) If an insurance
					 carrier or HMO performs utilization review only for coverage for which it is
					 the payor, the insurance carrier or HMO must be registered.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 19 - LICENSING AND REGULATION OF INSURANCE PROFESSIONALS › Subchapter R - UTILIZATION REVIEWS FOR HEALTH CARE PROVIDED UNDER A HEALTH BENEFIT PLAN OR HEALTH INSURANCE POLICY › Division 1 - UTILIZATION REVIEWS › Section 19.1705 - General Standards of Utilization Review

Current through Reg. 49, No. 28; July 12, 2024
(a) Review of utilization review plan. The
					 utilization review plan must be reviewed and approved by a physician licensed
					 to practice medicine in Texas and conducted under standards developed and
					 periodically updated with input from both primary and specialty physicians,
					 doctors, and other health care providers, as appropriate.
(b) Special circumstances.
(1) A utilization review determination must
					 be made in a manner that takes into account special circumstances of the case
					 that may require deviation from the norm stated in the screening criteria or
					 relevant guidelines. Special circumstances include, but are not limited to, an
					 individual who has a disability, acute condition, or life-threatening
					 illness.
(2) If coverage is
					 available for stage-four advanced, metastatic cancer and associated conditions,
					 as defined by Insurance Code §
												1369.211, the URA
					 cannot require, before coverage of a prescription drug, that the enrollee:
(A) fail to successfully respond to a
					 different drug; or
(B) prove a
					 history of failure of a different drug.
(3) Paragraph (2) of this subsection only
					 applies to a drug the use of which is:
(A)
					 consistent with best practices for the treatment of stage-four advanced,
					 metastatic cancer or an associated condition, as defined by Insurance Code
					 §
													1369.211;
(B) supported by peer-reviewed,
					 evidence-based literature; and
(C)
					 approved by the United States Food and Drug
					 Administration.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 19 - LICENSING AND REGULATION OF INSURANCE PROFESSIONALS › Subchapter R - UTILIZATION REVIEWS FOR HEALTH CARE PROVIDED UNDER A HEALTH BENEFIT PLAN OR HEALTH INSURANCE POLICY › Division 1 - UTILIZATION REVIEWS › Section 19.1706 - Requirements and Prohibitions Relating to Personnel

Current through Reg. 49, No. 28; July 12, 2024
(a) Qualification requirements. Physicians,
					 doctors, and other health care providers employed by or under contract with a
					 URA to perform utilization review must be appropriately trained, qualified, and
					 currently licensed. Personnel conducting utilization review must hold an
					 unrestricted license, an administrative license, or be otherwise authorized to
					 provide health care services by a licensing agency in the United States.
(1) This subchapter does not supersede
					 requirements in the Medical Practice Act; Texas Medical Board rules; Texas
					 Occupations Code Chapter 201 (relating to Chiropractors); or Texas Board of
					 Chiropractic Examiners rules. Individuals licensed by the Texas Medical Board
					 are subject to 22 TAC Chapter 190, regarding disciplinary guidelines.
(2) Personnel who perform clerical or
					 administrative tasks are not required to have the qualifications prescribed by
					 this subsection.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 19 - LICENSING AND REGULATION OF INSURANCE PROFESSIONALS › Subchapter R - UTILIZATION REVIEWS FOR HEALTH CARE PROVIDED UNDER A HEALTH BENEFIT PLAN OR HEALTH INSURANCE POLICY › Division 1 - UTILIZATION REVIEWS › Section 19.1707 - URA Contact with and Receipt of Information from Health Care Providers

Current through Reg. 49, No. 28; July 12, 2024
(a) If a URA must reimburse health care
					 providers for providing medical information under Insurance Code §
											4201.207,
					 reimbursement is limited to the reasonable costs for providing medical records
					 relevant to the utilization review that were requested by the URA in writing. A
					 health care provider's charge for providing medical information to a URA must
					 comply with §
											134.120
					 of this title (relating to Reimbursement for Medical Documentation) and may not
					 include any costs that are recouped as a part of the charge for health
					 care.
(b) When conducting routine
					 utilization review, the URA must request all relevant and updated information
					 and medical records to complete the review.
(1) This information may include identifying
					 information about the enrollee; the benefit plan or claim; the treating
					 physician, doctor, or other health care provider; and the facilities rendering
					 care. It may also include clinical and diagnostic testing information regarding
					 the diagnoses of the enrollee and the medical history of the enrollee relevant
					 to the diagnoses; the enrollee's prognosis; and the plan of treatment
					 prescribed by the provider of record, along with the provider of record's
					 justification for the plan of treatment. The required information should be
					 obtained from the appropriate source.
(2) URAs must not routinely request copies of
					 all medical records on enrollees reviewed. During utilization review, copies of
					 the necessary or pertinent sections of medical records should only be required
					 when a difficulty develops in determining whether the health care is medically
					 necessary or appropriate, or experimental or investigational.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 19 - LICENSING AND REGULATION OF INSURANCE PROFESSIONALS › Subchapter R - UTILIZATION REVIEWS FOR HEALTH CARE PROVIDED UNDER A HEALTH BENEFIT PLAN OR HEALTH INSURANCE POLICY › Division 1 - UTILIZATION REVIEWS › Section 19.1708 - On-Site Review by a URA

Current through Reg. 49, No. 28; July 12, 2024
(a) Identification
					 of URAs. If a URA's staff member is conducting an on-site or off-site review,
					 each staff member must provide his or her name, the name of his or her
					 organization, photo identification, and the URA identification card with the
					 certification or registration number assigned by TDI when requested by an
					 individual, including an enrollee or health care provider.
(b) On-site review. For on-site review
					 conducted at a health care facility, URAs:
(1) must ensure that their on-site review
					 staff:
(A) register with the appropriate
					 contact individual, if available, prior to requesting any clinical information
					 or assistance from health care facility staff; and
(B) wear appropriate health care facility
					 supplied identification tags while on the health care facility
					 premises;
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 19 - LICENSING AND REGULATION OF INSURANCE PROFESSIONALS › Subchapter R - UTILIZATION REVIEWS FOR HEALTH CARE PROVIDED UNDER A HEALTH BENEFIT PLAN OR HEALTH INSURANCE POLICY › Division 1 - UTILIZATION REVIEWS › Section 19.1710 - Requirements Prior to Issuing an Adverse Determination

Current through Reg. 49, No. 28; July 12, 2024
In any instance in which the URA is questioning the
						medical necessity, the appropriateness, or the experimental or investigational
						nature of the health care services prior to the issuance of an adverse
						determination, the URA must afford the provider of record a reasonable
						opportunity to discuss the plan of treatment for the enrollee with a physician
						licensed to practice medicine in Texas. The discussion must include, at a
						minimum, the clinical basis for the URA's decision and a description of
						documentation or evidence, if any, that can be submitted by the provider of
						record that, on appeal, might lead to a different utilization review decision.
						If the health care service was ordered, requested, or provided, or is to be
						provided, by a physician, then the opportunity must be with a physician
						licensed to practice medicine in Texas and who has the same or similar
						specialty as the physician.
(1) The
					 URA must provide the URA's telephone number so that the provider of record may
					 contact the URA to discuss the pending adverse determination.
(2) The URA must maintain, and submit to TDI
					 on request, documentation that details the discussion opportunity provided to
					 the provider of record, including the date and time the URA offered the
					 opportunity to discuss the adverse determination, the date and time that the
					 discussion, if any, took place, and the discussion outcome.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 19 - LICENSING AND REGULATION OF INSURANCE PROFESSIONALS › Subchapter R - UTILIZATION REVIEWS FOR HEALTH CARE PROVIDED UNDER A HEALTH BENEFIT PLAN OR HEALTH INSURANCE POLICY › Division 1 - UTILIZATION REVIEWS › Section 19.1712 - URA's Telephone Access

Current through Reg. 49, No. 28; July 12, 2024
(a)
					 Except as otherwise provided by the Insurance Code, a URA must have appropriate
					 personnel reasonably available by toll-free telephone at least 40 hours per
					 week during normal business hours in both Central Time and Mountain Time, to
					 discuss enrollees' care and to respond to telephone review requests.
(b) This section does not apply to an HMO or
					 preferred provider benefit plan that is subject to §
											19.1718
					 of this title (relating to Preauthorization for Health Maintenance
					 Organizations and Preferred Provider Benefit Plans) or §
											19.1719
					 of this title (relating to Verification for Health Maintenance Organizations
					 and Preferred Provider Benefit Plans).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 19 - LICENSING AND REGULATION OF INSURANCE PROFESSIONALS › Subchapter R - UTILIZATION REVIEWS FOR HEALTH CARE PROVIDED UNDER A HEALTH BENEFIT PLAN OR HEALTH INSURANCE POLICY › Division 1 - UTILIZATION REVIEWS › Section 19.1713 - Confidentiality

Current through Reg. 49, No. 28; July 12, 2024
(a) Confidentiality requirements. To ensure
					 confidentiality, a URA must, when contacting a physician's, doctor's, or other
					 health care provider's office, provide its certification number, name, and
					 professional qualifications.
(1) If requested
					 by the physician, doctor, or other health care provider, the URA must present
					 written documentation that it is acting as an agent of the payor for the
					 relevant enrollee.
(2) Medical
					 records and enrollee specific information must be maintained by the URA in a
					 secure area with access limited to essential personnel only.
(3) A URA must retain information generated
					 and obtained by a URA in the course of utilization review for at least four
					 years.
(4) A URA's charges for
					 providing a copy of recorded personal information to individuals may not exceed
					 10 cents per page and may not include any costs that are otherwise recouped as
					 part of the charge for utilization review.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 19 - LICENSING AND REGULATION OF INSURANCE PROFESSIONALS › Subchapter R - UTILIZATION REVIEWS FOR HEALTH CARE PROVIDED UNDER A HEALTH BENEFIT PLAN OR HEALTH INSURANCE POLICY › Division 1 - UTILIZATION REVIEWS › Section 19.1714 - Regulatory Requirements Subsequent to Certification or Registration

Current through Reg. 49, No. 28; July 12, 2024
(a) Complaints to TDI. Complaints received by
					 TDI against a URA must be processed under TDI's established procedures for
					 investigation and resolution of complaints.
(b) TDI inquiries. TDI may address inquiries
					 to a URA related to any matter connected with URA transactions that TDI
					 considers necessary for the public good or for the proper discharge of TDI's
					 duties. Under Insurance Code §
											38.001, a URA that
					 receives an inquiry from TDI must respond to the inquiry in writing not later
					 than the 15th day after the date the inquiry is received.
(c) On-site review by TDI. For scheduled and
					 unscheduled on-site reviews, TDI may make a complete on-site review of the
					 operations of each URA at the principal place of business for each agent as
					 often as is deemed necessary. An on-site review will only be conducted during
					 working days and normal business hours. The URA must make available all records
					 relating to its operation during any scheduled and unscheduled on-site review.
(1) Scheduled on-site reviews. URAs will be
					 notified of any scheduled on-site review by letter, which will specify, at a
					 minimum, the identity of TDI's designated representative and the expected
					 arrival date and time.
(2)
					 Unscheduled on-site reviews. At a minimum, notice of an unscheduled on-site
					 review of a URA will be in writing and be presented by TDI's designated
					 representative on arrival.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 19 - LICENSING AND REGULATION OF INSURANCE PROFESSIONALS › Subchapter R - UTILIZATION REVIEWS FOR HEALTH CARE PROVIDED UNDER A HEALTH BENEFIT PLAN OR HEALTH INSURANCE POLICY › Division 1 - UTILIZATION REVIEWS › Section 19.1715 - Administrative Violations

Current through Reg. 49, No. 28; July 12, 2024
A fraudulent or deceptive act or omission in obtaining,
						attempting to obtain, or use of certification or registration as a URA is a
						violation of Insurance Code Chapter 4201. The commissioner's authority under
						this subchapter is in addition to any other authority to enforce a sanction,
						penalty, fine, forfeiture, denial, suspension, or revocation otherwise
						authorized by law, including remedies under Insurance Code Chapter 4201,
						Subchapter M, concerning Enforcement.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 19 - LICENSING AND REGULATION OF INSURANCE PROFESSIONALS › Subchapter R - UTILIZATION REVIEWS FOR HEALTH CARE PROVIDED UNDER A HEALTH BENEFIT PLAN OR HEALTH INSURANCE POLICY › Division 1 - UTILIZATION REVIEWS › Section 19.1716 - Specialty URA

Current through Reg. 49, No. 28; July 12, 2024
(a) Application. To
					 be certified or registered as a specialty URA, an applicant must submit to TDI
					 the application, information, and fee required in §
											19.1704
					 of this title (relating to Certification or Registration of URAs).
(b) Same specialty required. A specialty URA
					 must 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 Texas. To conduct
					 utilization review, a specialty URA must be of the same specialty as the health
					 care provider who ordered the service. For example, when conducting utilization
					 review of prescription drugs prescribed by a physician with a specialty in
					 neurological surgery, the specialty URA must be a physician with a specialty in
					 neurological surgery.
(c) Rule
					 requirements. A specialty URA is subject to the requirements of this
					 subchapter, except for the following provisions:
(1) Section
					 19.1705(a)
					 of this title (relating to General Standards of Utilization Review);
(2) Section 19.1706(a), (c), and (d) of this
					 title (relating to Requirements and Prohibitions Relating to
					 Personnel);
(3) Section
					 19.1710
					 of this title (relating to Requirements Prior to Issuing Adverse
					 Determination); and
(4) Section
					 19.1711(a)(4) - (6) of this title (relating to Written Procedures for Appeal of
					 Adverse Determination).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 19 - LICENSING AND REGULATION OF INSURANCE PROFESSIONALS › Subchapter R - UTILIZATION REVIEWS FOR HEALTH CARE PROVIDED UNDER A HEALTH BENEFIT PLAN OR HEALTH INSURANCE POLICY › Division 1 - UTILIZATION REVIEWS › Section 19.1717 - Independent Review of Adverse Determinations

Current through Reg. 49, No. 28; July 12, 2024
(a) Notification for life-threatening
					 conditions. For life-threatening conditions, notification of adverse
					 determination by a URA must be provided within the timeframes specified in
					 §
											19.1709(e)(3)
					 of this title (relating to Notice of Determinations Made in Utilization
					 Review).
(1) At the time of notification of
					 the adverse determination, the URA must provide to the enrollee or individual
					 acting on behalf of the enrollee, and to the enrollee's provider of record, the
					 notice of the independent review process and a copy of the request for a review
					 by an IRO form. The notice must describe how to obtain independent review of
					 the adverse determination.
(2) The
					 enrollee, individual acting on behalf of the enrollee, or the enrollee's
					 provider of record must determine the existence of a life-threatening condition
					 on the basis that a prudent layperson possessing an average knowledge of
					 medicine and health would believe that the enrollee's disease or condition is a
					 life-threatening condition.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 19 - LICENSING AND REGULATION OF INSURANCE PROFESSIONALS › Subchapter R - UTILIZATION REVIEWS FOR HEALTH CARE PROVIDED UNDER A HEALTH BENEFIT PLAN OR HEALTH INSURANCE POLICY › Division 1 - UTILIZATION REVIEWS › Section 19.1719 - Verification for Health Maintenance Organizations and Preferred Provider Benefit Plans

Current through Reg. 49, No. 28; July 12, 2024
(a) The words and
					 terms defined in Insurance Code Chapter 1301, concerning Preferred Provider
					 Benefit Plans, and Chapter 843, concerning Health Maintenance Organizations,
					 have the same meaning when used in this section, except as otherwise provided
					 by this subchapter, unless the context clearly indicates otherwise. This
					 section applies to:
(1) HMOs;
(2) preferred provider benefit
					 plans;
(3) preferred providers;
					 and
(4) physicians, doctors, or
					 other health care providers that provide to an enrollee of an HMO or preferred
					 provider benefit plan:
(A) care related to an
					 emergency or its attendant episode of care as required by state or federal law;
					 or
(B) specialty or other medical
					 care or health care services at the request of the HMO, preferred provider
					 benefit plan, or a preferred provider because the services are not reasonably
					 available from a preferred provider who is included in the HMO or preferred
					 provider benefit plan's network.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 19 - LICENSING AND REGULATION OF INSURANCE PROFESSIONALS › Subchapter S - FORMS TO REQUEST PRIOR AUTHORIZATION › Division 1 - TEXAS STANDARD PRIOR AUTHORIZATION REQUEST FORMS › Section 19.1801 - Applicability

Current through Reg. 49, No. 28; July 12, 2024
(a) Applicable health benefit plans. This
					 subchapter applies only to a health benefit plan that provides benefits for
					 medical or surgical expenses incurred as a result of a health condition,
					 accident, or sickness, including an individual, group, blanket, or franchise
					 insurance policy or insurance agreement, a group hospital service contract, or
					 a small or large employer group contract or similar coverage document that is
					 offered by:
(1) an insurance
					 company;
(2) a group hospital
					 service corporation operating under Chapter 842;
(3) a fraternal benefit society operating
					 under Chapter 885;
(4) a stipulated
					 premium company operating under Chapter 884;
(5) a reciprocal exchange operating under
					 Chapter 942;
(6) a health
					 maintenance organization operating under Chapter 843;
(7) a multiple employer welfare arrangement
					 holding a certificate of authority under Chapter 846; or
(8) an approved nonprofit health corporation
					 holding a certificate of authority under Chapter 844.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 19 - LICENSING AND REGULATION OF INSURANCE PROFESSIONALS › Subchapter S - FORMS TO REQUEST PRIOR AUTHORIZATION › Division 1 - TEXAS STANDARD PRIOR AUTHORIZATION REQUEST FORMS › Section 19.1802 - Exception

Current through Reg. 49, No. 28; July 12, 2024
This subchapter does not apply to:
(1) a health benefit plan that provides
					 coverage:
(A) only for a specified disease or
					 for another single benefit;
(B)
					 only for accidental death or dismemberment;
(C) only for wages or payments to replace
					 wages for a period during which an employee is absent from work because of
					 sickness or injury;
(D) as a
					 supplement to a liability insurance policy;
(E) for credit insurance;
(F) only for dental or vision care;
(G) only for hospital expenses; or
(H) only for indemnity for hospital
					 confinement;
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 19 - LICENSING AND REGULATION OF INSURANCE PROFESSIONALS › Subchapter S - FORMS TO REQUEST PRIOR AUTHORIZATION › Division 1 - TEXAS STANDARD PRIOR AUTHORIZATION REQUEST FORMS › Section 19.1803 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms, when used in this
						subchapter, have the following meanings unless the context clearly indicates
						otherwise:
(1) CDT--Current Dental
					 Terminology code set maintained by the American Dental Association.
(2) CPT--Current Procedural Terminology code
					 set maintained by the American Medical Association.
(3) Department or TDI--Texas Department of
					 Insurance.
(4) Form--In Division 2
					 of this subchapter, the Texas Standard Prior Authorization Request Form for
					 Health Care Services. In Division 3 of this subchapter, the Texas Standard
					 Prior Authorization Request Form for Prescription Drug Benefits.
(5) HCPCS--Healthcare Common Procedure Coding
					 System.
(6) Health benefit plan--
(A) a plan that provides benefits for medical
					 or surgical expenses incurred as a result of a health condition, accident, or
					 sickness, including an individual, group, blanket, or franchise insurance
					 policy or insurance agreement, a group hospital service contract, or a small or
					 large employer group contract or similar coverage document offered by a health
					 benefit plan issuer.
(B) Health
					 benefit plan also includes:
(i) group health
					 coverage made available by a school district in accord with Education Code
					 §
													22.004;
(ii) coverage under the child health program
					 in Health and Safety Code Chapter 62, or the health benefits plan for children
					 in Health and Safety Code Chapter 63;
(iii) a Medicaid managed care program
					 operated under Government Code Chapter 533, or a Medicaid program operated
					 under Human Resources Code Chapter 32;
(iv) a basic coverage plan under Insurance
					 Code Chapter 1551;
(v) a basic plan
					 under Insurance Code Chapter 1575;
(vi) a primary care coverage plan under
					 Insurance Code Chapter 1579; and
(vii) basic coverage under Insurance Code
					 Chapter 1601.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 19 - LICENSING AND REGULATION OF INSURANCE PROFESSIONALS › Subchapter S - FORMS TO REQUEST PRIOR AUTHORIZATION › Division 1 - TEXAS STANDARD PRIOR AUTHORIZATION REQUEST FORMS › Section 19.1804 - Severability

Current through Reg. 49, No. 28; July 12, 2024
If a court of competent jurisdiction holds that any
						provision of this subchapter or its application to any person or circumstance
						is invalid for any reason, the invalidity does not affect other provisions or
						applications of this subchapter that can be given effect without the invalid
						provision or application, and to this end, the provisions of this subchapter
						are severable.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 19 - LICENSING AND REGULATION OF INSURANCE PROFESSIONALS › Subchapter T - SPECIALTY INSURANCE LICENSE › Section 19.1901 - Purpose

Current through Reg. 49, No. 28; July 12, 2024
The purpose of this subchapter is to implement licensing of
					 specialty agents as prescribed by Insurance Code Article 21.09 and to
					 facilitate the supervision of such activities in the public interest. The
					 purpose of a license issued under Insurance Code Article 21.09 and subject to
					 the provisions of this subchapter is to authorize and enable the specialty
					 licensee and its properly trained employees to actively engage in the
					 solicitation or sale of insurance as specified in Article 21.09 with respect to
					 the general public only in connection with an associated consumer
					 transaction.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 19 - LICENSING AND REGULATION OF INSURANCE PROFESSIONALS › Subchapter T - SPECIALTY INSURANCE LICENSE › Section 19.1902 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms, when used in this
					 subchapter, have the following meanings unless the context clearly indicates
					 otherwise.
(1) Associated consumer
				  transaction--A retail exchange of goods or services other than insurance which
				  is the basis of the relationship between the specialty license holder and its
				  customer.
(2) Control--The power to
				  direct or cause the direction of the management and policies of a specialty
				  license holder, whether directly or indirectly. For the purpose of this
				  subchapter, a person is considered to control:
(A) a corporate specialty license holder if
				  the person is an officer or director of the corporation or if the person,
				  individually or acting with others, directly or indirectly, holds with the
				  power to vote, owns, or controls, or holds proxies representing, at least 10%
				  of the voting stock or voting rights of the corporate specialty license holder;
				  or
(B) a partnership if the person
				  through a right to vote or through any other right or power exercises rights in
				  the management, direction, or conduct of the business of the
				  partnership.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 19 - LICENSING AND REGULATION OF INSURANCE PROFESSIONALS › Subchapter T - SPECIALTY INSURANCE LICENSE › Section 19.1903 - Qualifications

Current through Reg. 49, No. 28; July 12, 2024
(a) An individual may qualify for a specialty
				  license if the individual:
(1) is at least 18
				  years of age;
(2) has not committed
				  an act for which a license may be denied under the Insurance Code or insurance
				  regulations of this state or any other state; and
(3) satisfies the requirements of subsection
				  (c) of this section.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 19 - LICENSING AND REGULATION OF INSURANCE PROFESSIONALS › Subchapter T - SPECIALTY INSURANCE LICENSE › Section 19.1904 - Application

Current through Reg. 49, No. 28; July 12, 2024
(a) Application for more than one specialty
				  license authority. A first time applicant may seek licensure for more than one
				  specialty license authority on the same specialty license application. A $50
				  fee per specialty license authority must accompany the application.
(b) Assumed name or trade name. An applicant
				  desiring to use an assumed name in the conduct of an insurance business under a
				  specialty insurance license shall be subject to the requirements of §
										19.902 of
				  this title (relating to One Agent, One License) except that a separate filing
				  with the department shall not be required for an applicant who conducts
				  business under a single assumed name and registers that name with the
				  department on the applicant's original specialty license application. No
				  applicant for or holder of a specialty license shall be required to file
				  multiple registrations with the department for a previously registered assumed
				  name as a result of seeking more than one specialty license
				  authority.
(c) Forms. Application
				  and Registration forms are available by:
(1)
				  contacting the department's licensing division customer service center;
				  or
(2) through the department's
				  website at www.tdi.state.tx.us.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 19 - LICENSING AND REGULATION OF INSURANCE PROFESSIONALS › Subchapter T - SPECIALTY INSURANCE LICENSE › Section 19.1906 - Expiration and Renewal of Licenses

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  Except as may be provided under §
										19.801
				  of this title (relating to General Provisions Regarding Licensing Fees and
				  License Renewal), each specialty license issued by the department expires on
				  the second anniversary of the date of issuance unless suspended or revoked by
				  the commissioner. A specialty license holder may renew a license that has not
				  expired or has not been suspended or revoked by filing a properly completed
				  renewal application with the department in the form prescribed by the
				  department and paying to the department before the expiration date of the
				  license the required renewal fee as specified in §
										19.802
				  of this title (relating to Amounts of Fees). A renewal fee is
				  nonrefundable.
(b) The provisions
				  of Insurance Code Article 21.01-2 §2 concerning the renewal of an
				  insurance agent license shall apply to the specialty license issued under
				  Insurance Code Article 21.09 and this subchapter.
(c) When a complete renewal application is
				  filed not later than the expiration date of the license and accompanied by the
				  renewal fee specified in §
										19.802
				  of this title, the original license continues in force until:
(1) the department issues the renewal
				  license; or
(2) the commissioner
				  issues an order suspending or revoking the license.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 19 - LICENSING AND REGULATION OF INSURANCE PROFESSIONALS › Subchapter T - SPECIALTY INSURANCE LICENSE › Section 19.1907 - Non-Residents

Current through Reg. 49, No. 28; July 12, 2024
A specialty license shall be issued to persons not resident
					 in the State of Texas under the same requirements applicable to Texas
					 residents.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 19 - LICENSING AND REGULATION OF INSURANCE PROFESSIONALS › Subchapter T - SPECIALTY INSURANCE LICENSE › Section 19.1908 - Notice to Department

Current through Reg. 49, No. 28; July 12, 2024
Each specialty license holder must notify the department
					 within 30 days of the occurrence of the following:
(1) a change of the specialty license
				  holder's mailing address;
(2) an
				  administrative action taken against the specialty license holder by the
				  insurance regulator of another state;
(3) a felony conviction of the specialty
				  license holder or any individual who exercises control of the specialty license
				  holder; or
(4) the addition or
				  removal of an officer, director, partner, member, manager, or any other person
				  in control of the specialty license holder.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 19 - LICENSING AND REGULATION OF INSURANCE PROFESSIONALS › Subchapter T - SPECIALTY INSURANCE LICENSE › Section 19.1909 - Employee Training

Current through Reg. 49, No. 28; July 12, 2024
(a) Each employee
				  of a specialty license holder who performs any act of an insurance agent shall
				  complete a training program which satisfies the requirements of Article 21.09
				  §1(d).
(b) An insurance
				  company authorized to write the specialty insurance product shall submit an
				  outline of the training program to the department for approval prior to use by
				  a specialty license holder.
(c) The
				  training outline shall be sufficiently detailed to demonstrate that the
				  specialty license applicant's employees will receive training in the
				  disclosures required under the applicable statutes and regulations as well as
				  training in each specific type of specialty insurance product which the
				  applicant seeks authorization to solicit.
(d) An applicant for or holder of a specialty
				  insurance license shall submit all employee training materials to the
				  department upon request. If the department finds that a training program is
				  deficient, misrepresents any aspect of the insurance transaction or contains
				  inaccuracies misleading to the public, the department may institute a
				  disciplinary action against the insurance company that prepared the training
				  materials. If the department finds that a training program is modified by or is
				  not properly administered by the specialty license holder, the department may
				  take any disciplinary action authorized under §
										19.1910
				  of this title (relating to Denial or Refusal of Specialty License Application;
				  Suspension or Revocation of Specialty Licenses; Discipline of Specialty License
				  Holders) against the specialty license holder.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 19 - LICENSING AND REGULATION OF INSURANCE PROFESSIONALS › Subchapter T - SPECIALTY INSURANCE LICENSE › Section 19.1910 - Denial Or Refusal Of Specialty License Application; Suspension Or Revocation Of Specialty Licenses; Discipline Of Specialty License Holders

Current through Reg. 49, No. 28; July 12, 2024
(a) In addition to any other remedy available
				  under Chapter 82 of the Insurance Code, the department may refuse to issue an
				  original license, revoke, suspend, or refuse to renew a license, place on
				  probation a person whose license has been suspended, assess an administrative
				  penalty, or reprimand a specialty license holder for a violation of the
				  Insurance Code, another insurance law of this state, or a rule of the
				  department. If a license suspension is probated, the commissioner may require
				  the license holder to:
(1) report regularly
				  to the department on matters that are the basis of the probation;
(2) limit the person's practice to the areas
				  prescribed by the department; or
(3) continue or review professional education
				  until the person attains a degree of skill satisfactory to the commissioner in
				  those areas that are the basis of the probation.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 19 - LICENSING AND REGULATION OF INSURANCE PROFESSIONALS › Subchapter U - UTILIZATION REVIEWS FOR HEALTH CARE PROVIDED UNDER WORKERS' COMPENSATION INSURANCE COVERAGE › Section 19.2001 - General Provisions

Current through Reg. 49, No. 28; July 12, 2024
(a) Statutory
				  basis. This subchapter implements Insurance Code Chapter 4201, concerning
				  Utilization Review Agents; Insurance Code Chapter 1305, concerning Workers'
				  Compensation Health Care Networks; and Labor Code Title 5, concerning Workers'
				  Compensation.
(b) Severability. If
				  a court of competent jurisdiction holds that any provision of this subchapter
				  or its application to any person or circumstance is invalid for any reason, the
				  invalidity does not affect other provisions or applications of this subchapter
				  that can be given effect without the invalid provision or application, and to
				  this end the provisions of this subchapter are severable.
(c) Purpose. The purpose of this subchapter
				  is to:
(1) promote the delivery of quality
				  health care in a cost-effective manner, including protection of injured
				  employee safety;
(2) ensure that
				  URAs adhere to reasonable standards for conducting utilization
				  reviews;
(3) foster greater
				  coordination and cooperation between health care providers and URAs;
(4) improve communications and knowledge of
				  medical benefits among all parties concerned before expenses are incurred;
				  and
(5) ensure that URAs maintain
				  the confidentiality of medical records under applicable law.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 19 - LICENSING AND REGULATION OF INSURANCE PROFESSIONALS › Subchapter U - UTILIZATION REVIEWS FOR HEALTH CARE PROVIDED UNDER WORKERS' COMPENSATION INSURANCE COVERAGE › Section 19.2002 - Applicability

Current through Reg. 49, No. 28; July 12, 2024
(a) Limitations on applicability. Except as
				  provided in Insurance Code Chapter 4201, this subchapter applies to utilization
				  review performed under workers' compensation insurance coverage. This
				  subchapter does not affect the authority of TDI-DWC to exercise the powers
				  granted to it under Labor Code Title 5 and Insurance Code Chapter 4201. This
				  subchapter applies to utilization review as set forth in Insurance Code
				  Chapters 1305 and 4201 and Labor Code Title 5.
(1) This subchapter does not apply to
				  utilization review performed under a health benefit plan or a health insurance
				  policy.
(2) This subchapter does
				  not apply to a person who provides information to an injured employee or an
				  injured employee's representative, physician, doctor, or other health care
				  provider about scope of coverage or benefits provided for under workers'
				  compensation insurance coverage, and does not determine medical necessity or
				  appropriateness or the experimental or investigational nature of health care
				  services.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 19 - LICENSING AND REGULATION OF INSURANCE PROFESSIONALS › Subchapter U - UTILIZATION REVIEWS FOR HEALTH CARE PROVIDED UNDER WORKERS' COMPENSATION INSURANCE COVERAGE › Section 19.2004 - Certificate or Registration of URAs

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  Applicability of certification or registration requirements. A person acting as
				  or holding itself out as a URA under this subchapter must be certified or
				  registered, as applicable, under Insurance Code §
										4201.057, concerning
				  Health Maintenance Organizations; Insurance Code §
										4201.058, concerning
				  Insurers; or Insurance Code §
										4201.101, concerning
				  Certificate of Registration Required, and this subchapter.
(1) If an insurance carrier performs
				  utilization review for an individual or entity subject to this subchapter for
				  which it is not the payor, the insurance carrier must be certified.
(2) If an insurance carrier performs
				  utilization review only for coverage for which it is the payor, the insurance
				  carrier must be registered.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 19 - LICENSING AND REGULATION OF INSURANCE PROFESSIONALS › Subchapter U - UTILIZATION REVIEWS FOR HEALTH CARE PROVIDED UNDER WORKERS' COMPENSATION INSURANCE COVERAGE › Section 19.2006 - Requirements and Prohibitions Relating to Personnel

Current through Reg. 49, No. 28; July 12, 2024
(a) Qualification requirements. Physicians,
				  doctors, and other health care providers employed by or under contract with a
				  URA to perform utilization review must be appropriately trained, qualified, and
				  currently licensed. Personnel conducting utilization review must hold an
				  unrestricted license or an administrative license in Texas or be otherwise
				  authorized to provide health care services in Texas. Physicians and doctors
				  conducting utilization review must hold a professional certification in a
				  health care specialty appropriate to the type of health care the injured
				  employee is receiving as required by Labor Code §§
										408.0043,
				  408.0044,
				  and
				  408.0045.
				  Physicians, doctors, and other health care providers conducting utilization
				  review must have the appropriate credentials as required by Chapter 180 of this
				  title (relating to Monitoring and Enforcement).
(1) This subchapter does not supersede
				  requirements in the Medical Practice Act, Texas Medical Board rules, Texas
				  Occupations Code Chapter 201 (relating to Chiropractors), or Texas Board of
				  Chiropractic Examiners rules. Individuals licensed by the Texas Medical Board
				  are subject to 22 TAC Chapter 190, regarding disciplinary guidelines.
(2) Personnel who perform clerical or
				  administrative tasks are not required to have the qualifications prescribed by
				  this subsection.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 19 - LICENSING AND REGULATION OF INSURANCE PROFESSIONALS › Subchapter U - UTILIZATION REVIEWS FOR HEALTH CARE PROVIDED UNDER WORKERS' COMPENSATION INSURANCE COVERAGE › Section 19.2007 - URA Contact with and Receipt of Information from Health Care Providers

Current through Reg. 49, No. 28; July 12, 2024
(a) If a URA must reimburse health care
				  providers for providing medical information under Insurance Code §
										4201.207,
				  reimbursement is limited to the reasonable costs for providing medical records
				  relevant to the utilization review that were requested by the URA in writing. A
				  health care provider's charge for providing medical information to a URA must
				  comply with §
										134.120
				  of this title (relating to Reimbursement for Medical Documentation) and may not
				  include any costs that are recouped as a part of the charge for health care.
				  Nothing in this subsection removes the health care provider's requirement to
				  provide information to substantiate the medical necessity of health care
				  requested under Chapter 134 of this title (relating to Benefits--Guidelines for
				  Medical Services, Charges, and Payments) or to submit required documentation
				  when submitting a medical bill under Chapter 133 of this title (relating to
				  General Medical Provisions).
(b)
				  When conducting utilization review, a URA must request all relevant and updated
				  information and medical records to complete the review.
(1) This information may include identifying
				  information about the injured employee; the claim; the treating physician,
				  doctor, or other health care provider; and the facilities rendering care. It
				  may also include clinical and diagnostic testing information regarding the
				  diagnoses of the injured employee and the medical history of the injured
				  employee relevant to the diagnoses and the compensable injury, the injured
				  employee's prognosis, and the plan of treatment prescribed by the provider of
				  record, along with the provider of record's justification for the plan of
				  treatment. The required information should be requested from the appropriate
				  sources.
(2) A URA must not
				  routinely request copies of all medical records on injured employees reviewed.
				  During utilization review, copies of the necessary or pertinent sections of
				  medical records should only be required when a difficulty develops in
				  determining whether the health care is medically necessary or appropriate or
				  experimental or investigational in nature.