reglab/statecodes huggingface dataset:
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 12 - INDEPENDENT REVIEW ORGANIZATIONS › Subchapter A - GENERAL PROVISIONS › Section 12.6 - Independent Review of Adverse Determinations of Health Care Provided Under Labor Code Title 5 or Insurance Code Chapter 1305

Current through Reg. 49, No. 28; July 12, 2024
(a) Review of the medical necessity or
				  appropriateness of a health care service provided under Labor Code Chapter 408
				  or Chapter 413 must be conducted under this chapter in the same manner as
				  reviews of utilization review decisions by health maintenance
				  organizations.
(b) Notwithstanding
				  subsection (a) of this section, for independent review of adverse
				  determinations of health care provided under Labor Code Title 5 or Insurance
				  Code Chapter 1305:
(1) IROs and personnel
				  conducting independent review must comply with Labor Code Title 5 and
				  applicable TDI-DWC rules;
(2) in
				  the event of a conflict between this chapter and the Labor Code, the Labor Code
				  controls; and
(3) in the event of a
				  conflict between this chapter and TDI-DWC rules, TDI-DWC rules
				  control.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 12 - INDEPENDENT REVIEW ORGANIZATIONS › Subchapter B - CERTIFICATE OF REGISTRATION FOR INDEPENDENT REVIEW ORGANIZATIONS › Section 12.101 - Certificate of Registration for Independent Review

Current through Reg. 49, No. 28; July 12, 2024
An application for a certificate of registration and for
					 renewal of a certificate of registration as an IRO and associated fees must be
					 filed with the Texas Department of Insurance at the following address: Texas
					 Department of Insurance, Mail Code 103-6A, P.O. Box 149104, Austin, Texas
					 78714-9104.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 12 - INDEPENDENT REVIEW ORGANIZATIONS › Subchapter B - CERTIFICATE OF REGISTRATION FOR INDEPENDENT REVIEW ORGANIZATIONS › Section 12.102 - IRO Application Form

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  Applicants must submit the IRO application form for an original application
				  for, renewal of, and reporting a material change in an IRO application form for
				  a certificate of registration as an IRO in this state in the format prescribed
				  by the department.
(b) The
				  commissioner adopts the biographical affidavit by reference to be used as an
				  attachment to the IRO application form.
(c) The forms are available at
				  www.tdi.texas.gov/forms. Applicants may also obtain the forms from the Texas
				  Department of Insurance, Mail Code 103-6A, P.O. Box 149104, Austin, Texas
				  78714-9104.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 12 - INDEPENDENT REVIEW ORGANIZATIONS › Subchapter B - CERTIFICATE OF REGISTRATION FOR INDEPENDENT REVIEW ORGANIZATIONS › Section 12.103 - Information Required in Original Application for Certificate of Registration

Current through Reg. 49, No. 28; July 12, 2024
The IRO application form requires information that is
					 necessary for the commissioner to determine whether an applicant is qualified
					 for a certificate of registration as an IRO under Insurance Code §
					 4202.004, including:
(1) a summary of
				  the independent review plan that meets the requirements of §
										12.201 of
				  this chapter, which must include:
(A) a
				  summary description of review criteria and review procedures to be used to
				  determine medical necessity or appropriateness of health care;
(B) a summary description of review criteria
				  and review procedures to be used to determine the experimental or
				  investigational nature of health care;
(C) a certification signed by the IRO's
				  medical director that the review criteria and review procedures to be applied
				  in review determinations are established with input from appropriate health
				  care providers and approved by physicians under §
											12.201(3)
				  of this chapter;
(D) procedures
				  ensuring that the information regarding the reviewing physicians and providers
				  is updated under § 12.111(a) of this chapter to ensure the independence of
				  each health care provider or physician making review determinations;
				  and
(E) a summary description of
				  criteria and review procedures to be used by the medical director to conduct
				  quality assurance audits under §
											12.202(c)(2)
				  of this chapter.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 12 - INDEPENDENT REVIEW ORGANIZATIONS › Subchapter B - CERTIFICATE OF REGISTRATION FOR INDEPENDENT REVIEW ORGANIZATIONS › Section 12.104 - Review of Original Application

Current through Reg. 49, No. 28; July 12, 2024
The original application process is as follows:
(1) Original application process. Within 60
				  days after receipt of a complete original application, the department will
				  process the application and grant or deny an original certificate of
				  registration. The department will send a certificate of registration to an
				  entity that is granted a certificate of registration. The applicant may waive
				  the time limit described in this paragraph.
(2) Omissions or deficiencies.
(A) The department will send the applicant
				  written notice of any omissions or deficiencies in the original
				  application.
(B) The applicant must
				  correct the omissions or deficiencies in the application within 15 days of the
				  date of the department's latest notice of omissions or deficiencies. The
				  applicant may request additional time, not to exceed 30 days, in writing, to
				  correct the omissions or deficiencies. In the request, the applicant must
				  include sufficient detail for the commissioner to determine whether there is
				  good cause to grant additional time for the applicant to correct the omissions
				  or deficiencies. The decision to grant or deny a request for additional time is
				  at the discretion of the commissioner.
(C) If the applicant fails to correct the
				  omissions or deficiencies within 15 days, or 45 days if the applicant requested
				  and was granted the maximum amount of additional time, the department will
				  close the application as incomplete. The application fee is not
				  refundable.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 12 - INDEPENDENT REVIEW ORGANIZATIONS › Subchapter B - CERTIFICATE OF REGISTRATION FOR INDEPENDENT REVIEW ORGANIZATIONS › Section 12.105 - Revisions During Review Process

Current through Reg. 49, No. 28; July 12, 2024
Revisions made by the applicant during the review of the
					 application must either be submitted electronically in the manner specified by
					 the department in correspondence with the applicant or sent by mail addressed
					 to: Texas Department of Insurance, Mail Code 103-6A, P.O. Box 149104, Austin,
					 Texas 78714-9104. If a page is revised, the revised page submitted by the
					 applicant must contain the changed item or information
					 red-lined.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 12 - INDEPENDENT REVIEW ORGANIZATIONS › Subchapter B - CERTIFICATE OF REGISTRATION FOR INDEPENDENT REVIEW ORGANIZATIONS › Section 12.106 - Examinations

Current through Reg. 49, No. 28; July 12, 2024
(a) The commissioner may conduct an on-site
				  examination at the applicant's primary office as a requirement of applying for
				  a certificate of registration.
(b)
				  The commissioner may conduct examinations of an IRO as often as the
				  commissioner deems necessary to determine compliance with Insurance Code
				  Chapter 4202 and this chapter, including on renewal of the certificate of
				  registration.
(c) The following
				  documents must be available for review during an examination at the primary
				  office of the IRO located within this state:
(1) the information required in §
											12.103
				  of this chapter;
(2) credentialing
				  files;
(3) case decisions
				  files;
(4) a list of personnel who
				  are available at the IRO's primary office 40 hours a week during normal
				  business hours in both Central and Mountain time zones;
(5) a list of directors, officers, and
				  executives and owners or shareholders, or if the IRO is publicly held, owners
				  or shareholders of more than 5 percent of any of the IRO's stock or options as
				  described by Insurance Code § 4202.004(a)(1);
(6) a chart showing the internal
				  organizational structure of the IRO management and administrative
				  staff;
(7) a chart showing the
				  contractual relationships and arrangements of the IRO, as described in §
											12.103
				  of this chapter; and
(8) any other
				  documents related to the operation of the IRO.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 12 - INDEPENDENT REVIEW ORGANIZATIONS › Subchapter B - CERTIFICATE OF REGISTRATION FOR INDEPENDENT REVIEW ORGANIZATIONS › Section 12.107 - Withdrawal of an Original Application Before Granting a Certificate of Registration and Subsequent Renewal Applications

Current through Reg. 49, No. 28; July 12, 2024
(a) On written notice to the department, an
				  applicant may request withdrawal of an application from consideration by the
				  department.
(b) On the department's
				  receipt of a request to withdraw an application under this section, the
				  application will be withdrawn from consideration. Subsequent applications by
				  the same applicant must be new submissions in their entirety.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 12 - INDEPENDENT REVIEW ORGANIZATIONS › Subchapter B - CERTIFICATE OF REGISTRATION FOR INDEPENDENT REVIEW ORGANIZATIONS › Section 12.108 - Renewal of Certificate of Registration

Current through Reg. 49, No. 28; July 12, 2024
(a) Every two years, the commissioner will
				  renew the certificate of registration of each organization that meets the
				  standards as an IRO.
(b) An IRO
				  must apply for renewal of its certificate of registration every two years, no
				  later than the anniversary date of the issuance of the registration. The IRO
				  application form must be used for this purpose. The IRO application form may be
				  obtained from the department's website and from the address listed in §
										12.102(c)
				  of this chapter. The completed IRO application form, renewal fee, and a
				  certification that no material changes exist that have not already been filed
				  with the department must be submitted to the department at the address listed
				  in §
										12.101
				  of this chapter.
(c) An IRO may
				  continue to operate under its certificate of registration after a completed
				  application form and renewal fee have been received by the department and until
				  the renewal is finally denied or granted by the department. However,
				  independent reviews will not be assigned to an IRO during the 30 days before
				  the anniversary date of the issuance of the IRO's certificate of registration
				  unless a completed renewal application form and the application fee have been
				  received by the department.
(d) If
				  a completed renewal application form is not received before the anniversary
				  date of the year in which the certificate of registration must be renewed, the
				  certificate of registration will automatically expire and the IRO must complete
				  and submit a new application for certificate of registration.
(e) Until the certificate of registration
				  renewal application process is complete or the certificate of registration
				  expires, an IRO must:
(1) continue to perform
				  its duties in compliance with Insurance Code Chapter 4202, the Labor Code, and
				  department and TDI-DWC rules, including maintenance and retention of medical
				  records and patient-specific information under §
											12.208
				  of this chapter; and
(2) in regard
				  to reviews of the medical necessity of a health care service provided under
				  Labor Code Title 5 or Insurance Code Chapter 1305, make responses to requests
				  for letters of clarification under §
											133.308
				  of this title.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 12 - INDEPENDENT REVIEW ORGANIZATIONS › Subchapter B - CERTIFICATE OF REGISTRATION FOR INDEPENDENT REVIEW ORGANIZATIONS › Section 12.109 - Appeal of Denial of Application or Renewal

Current through Reg. 49, No. 28; July 12, 2024
If an original or renewal application is denied under this
					 chapter, the applicant or registrant may appeal the denial under the provisions
					 of Chapter 1, Subchapter A of this title and Government Code, Chapter
					 2001.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 12 - INDEPENDENT REVIEW ORGANIZATIONS › Subchapter B - CERTIFICATE OF REGISTRATION FOR INDEPENDENT REVIEW ORGANIZATIONS › Section 12.110 - Effect of Sale or Transfer of Ownership of an Independent Review Organization

Current through Reg. 49, No. 28; July 12, 2024
(a) An IRO must
				  notify the department of an agreement to sell or transfer the ownership of the
				  IRO, or shares in the IRO, no later than 60 days before the date of the sale or
				  transfer of ownership. The IRO must use the IRO application form. The IRO must
				  file the notification with the department at the following address: Texas
				  Department of Insurance, Mail Code 103-6A, P.O. Box 149104, Austin, Texas
				  78714-9104. The IRO must submit the following information with the
				  notification:
(1) name of the purchaser and,
				  in compliance with §
											1.503
				  and §
											1.504 of
				  this title, a complete and legible set of fingerprints for each officer of the
				  purchaser and for each owner or shareholder of the purchaser, or if the
				  purchaser is publicly held, each owner or shareholder of more than 5 percent of
				  any of the purchaser's stock or options as described by Insurance Code §
				  4202.004(a)(1), and any additional information necessary to comply with
				  Insurance Code § 4202.004(d); and
(2) any material changes including, but not
				  limited to, policies and procedures, physical address, personnel, or operating
				  locations with the notice of intent to sell or transfer ownership.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 12 - INDEPENDENT REVIEW ORGANIZATIONS › Subchapter B - CERTIFICATE OF REGISTRATION FOR INDEPENDENT REVIEW ORGANIZATIONS › Section 12.111 - Regulatory Requirements Subsequent to a Certificate of Registration

Current through Reg. 49, No. 28; July 12, 2024
(a) The IRO must report any material changes
				  to the information required in the IRO application form required by §
										12.103
				  and §
										12.108
				  of this chapter, including changes relating to physicians and providers
				  performing independent review, no later than the 30th day after the date on
				  which the change takes effect.
(b)
				  If the material change is a relocation of the primary office:
(1) the organization must inform the
				  department that the location is available for inspection by the department at
				  least 30 days before the date of the relocation;
(2) on request of the department, an officer
				  must attend the inspection; and
(3)
				  if the inspection is a result of a sale under §
											12.110
				  of this chapter, the inspection may include verification that the IRO complies
				  with the requirements in §
											12.103(11)
				  of this chapter.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 12 - INDEPENDENT REVIEW ORGANIZATIONS › Subchapter C - GENERAL STANDARDS OF INDEPENDENT REVIEW › Section 12.201 - Independent Review Plan

Current through Reg. 49, No. 28; July 12, 2024
Independent review must be conducted under an independent
					 review plan that is consistent with standards developed with input from
					 appropriate health care providers, and reviewed and approved by the IRO's
					 medical director. The independent review plan must include the following
					 components:
(1) a description of the
				  elements of review that the IRO provides;
(2) written procedures for:
(A) notification of the IRO's determinations
				  provided to the patient or a representative of the patient, the patient's
				  provider of record, and the utilization review agent, under §
											12.206
				  of this chapter;
(B) review,
				  including:
(i) any form used during the
				  review process;
(ii) time frames
				  that must be met during the review;
(C) accessing appropriate specialty
				  review;
(D) contacting and
				  receiving information from health care providers under §
											12.205
				  of this chapter;
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 12 - INDEPENDENT REVIEW ORGANIZATIONS › Subchapter C - GENERAL STANDARDS OF INDEPENDENT REVIEW › Section 12.202 - Personnel and Credentialing

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  Personnel employed by or under contract with the IRO to perform independent
				  reviews must be appropriately trained, qualified, and, if applicable, currently
				  licensed, registered, or certified. These personnel must be currently involved
				  in an active practice. An exception to the active practice requirement is the
				  medical director of the IRO. Personnel who obtain information directly from a
				  physician, dentist, or other health care provider, either orally or in writing,
				  and who are not physicians or dentists, must be nurses, physician assistants,
				  or health care providers qualified to provide the service requested by the
				  provider. This provision must not be interpreted to require such qualifications
				  for personnel who perform clerical or administrative tasks.
(1) Personnel conducting independent reviews
				  for health services must hold an unrestricted license, an administrative
				  license, or otherwise be authorized to provide the same or similar specialty
				  health services by a licensing agency in the United States.
(2) Personnel conducting independent reviews
				  for workers' compensation health care services must hold an unrestricted
				  license, an administrative license, or otherwise be authorized to provide the
				  same or similar specialty workers' compensation health care services by a
				  licensing agency in this state.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 12 - INDEPENDENT REVIEW ORGANIZATIONS › Subchapter C - GENERAL STANDARDS OF INDEPENDENT REVIEW › Section 12.203 - Conflicts of Interest Prohibited

Current through Reg. 49, No. 28; July 12, 2024
A person is not eligible for a certificate of registration
					 under this chapter if any payor, or trade or professional association of
					 payors, has any ownership interest in or control over the person or if the
					 person has any ownership interest in or control over a payor. The department
					 will have the discretion to determine whether any other conflicts
					 exist.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 12 - INDEPENDENT REVIEW ORGANIZATIONS › Subchapter C - GENERAL STANDARDS OF INDEPENDENT REVIEW › Section 12.204 - Prohibitions of Certain Activities and Relationships of Independent Review Organizations and Individuals or Entities Associated with Independent Review Organizations

Current through Reg. 49, No. 28; July 12, 2024
(a) An IRO must
				  not set or impose any notice or other review procedures that are contrary to
				  the requirements of the health insurance policy or health benefit plan unless
				  those requirements are set out in this chapter or Texas law.
(b) An IRO may not permit or provide
				  compensation or anything of value to its physicians or providers that would
				  affect, directly or indirectly, an independent review decision.
(c) An IRO may not operate out of the same
				  office or other facility as another IRO.
(1)
				  This prohibition extends to the shared use by IROs of the resources and staff
				  that comprise an office, including office space, telephone and fax lines,
				  electronic equipment, supplies, and clerical staff.
(2) This prohibition does not extend to the
				  use of subcontractor services or personnel employed by or under contract with
				  the IRO to perform independent review.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 12 - INDEPENDENT REVIEW ORGANIZATIONS › Subchapter C - GENERAL STANDARDS OF INDEPENDENT REVIEW › Section 12.206 - Notice of Determinations Made by Independent Review Organizations

Current through Reg. 49, No. 28; July 12, 2024
(a) An IRO must notify the patient or
				  patient's representative, the patient's provider of record, the utilization
				  review agent, the payor, and the department of a determination made in an
				  independent review.
(b) For a
				  situation other than a situation described in subsection (c) of this section,
				  the notification required by this section must be mailed or otherwise
				  transmitted no later than the earlier of:
(1)
				  The 15th day after the date the IRO receives the information necessary to make
				  a determination; or
(2) the 20th
				  day after the date the IRO receives the request for the independent
				  review.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 12 - INDEPENDENT REVIEW ORGANIZATIONS › Subchapter C - GENERAL STANDARDS OF INDEPENDENT REVIEW › Section 12.207 - Independent Review Organization Telephone Access

Current through Reg. 49, No. 28; July 12, 2024
(a) An IRO must have appropriate personnel
				  reasonably available by telephone at least 40 hours per week during normal
				  business hours in both Central and Mountain time zones.
(b) An IRO must have a dedicated telephone
				  system capable of accepting or recording or providing instructions to incoming
				  callers related to independent review during other-than-normal business hours,
				  and must respond to calls no later than one working day from the date the call
				  was received.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 12 - INDEPENDENT REVIEW ORGANIZATIONS › Subchapter D - ENFORCEMENT OF INDEPENDENT REVIEW STANDARDS › Section 12.301 - Complaints, Oversight, and Information

Current through Reg. 49, No. 28; July 12, 2024
(a) Complaints against an IRO must be
				  processed under the department's established procedures for investigation and
				  resolution of complaints.
(b) As
				  part of its oversight of IROs, the department will conduct compliance audits to
				  ensure that IROs are complying with Insurance Code Chapters 1305 and 4202 and
				  the rules and standards in this chapter.
(c) The department may use the authority of
				  Insurance Code § 38.001 to make inquiries of any IRO.
(d) This chapter does not limit the ability
				  of the commissioner of workers' compensation or TDI-DWC to make inquiries,
				  conduct audits, or receive and investigate complaints against IROs or personnel
				  employed by or under contract with IROs to perform independent review to
				  determine compliance with or violations of Labor Code Title 5 or applicable
				  TDI-DWC rules.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 12 - INDEPENDENT REVIEW ORGANIZATIONS › Subchapter D - ENFORCEMENT OF INDEPENDENT REVIEW STANDARDS › Section 12.302 - Administrative Violations

Current through Reg. 49, No. 28; July 12, 2024
(a) If the
				  department believes that any person conducting independent review is in
				  violation of Insurance Code Chapters 1305 or 4202; any provision of Labor Code
				  Chapters 408, 409, or 413; or this chapter or Chapters 19, 133, 134, 140, or
				  180 of this title, respectively, the department will notify the IRO of the
				  alleged violation and may compel the production of any and all documents or
				  other information necessary to determine whether or not a violation has taken
				  place.
(b) The department or
				  TDI-DWC may initiate appropriate proceedings under this chapter or Labor Code
				  Title 5 and TDI-DWC rules.
(c)
				  Proceedings under this chapter are contested cases for the purpose of
				  Government Code Chapter 2001.
(d)
				  If the commissioner determines that an IRO or a person conducting independent
				  reviews has violated or is violating any provision of Insurance Code Chapter
				  4202 or this chapter, the commissioner may:
(1) impose sanctions under Insurance Code
				  Chapter 82;
(2) issue a cease and
				  desist order under Insurance Code Chapter 83; and
(3) assess administrative penalties under
				  Insurance Code Chapter 84.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 12 - INDEPENDENT REVIEW ORGANIZATIONS › Subchapter D - ENFORCEMENT OF INDEPENDENT REVIEW STANDARDS › Section 12.303 - Surrender of Certificate of Registration

Current through Reg. 49, No. 28; July 12, 2024
(a) Under Insurance Code §
				  4202.002(c)(2)(B) an IRO that enters into an agreed order with the department
				  that includes surrendering its certificate of registration, must surrender the
				  organization's certificate of registration immediately on the request of the
				  department.
(b) Independent reviews
				  will not be assigned to an IRO during a surrender of the IRO's certificate of
				  registration.
(c) Surrender of an
				  IRO's certificate of registration does not negate the requirement in §
										12.208(i)
				  of this subchapter that an IRO must retain information generated and obtained
				  by the IRO in the course of a review for at least four years or the obligation
				  to complete all independent reviews assigned to the IRO before its the
				  surrender of the certificate of registration.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 12 - INDEPENDENT REVIEW ORGANIZATIONS › Subchapter E - FEES AND PAYMENT › Section 12.401 - Fees

Current through Reg. 49, No. 28; July 12, 2024
(a) The commissioner will establish,
				  administer, and enforce the application and renewal of certificate of
				  registration fees under this section in amounts not greater than necessary to
				  cover the cost of administration of this chapter.
(b) Fees for independent review will be
				  determined by the commissioner, and will reflect in general the market value of
				  services rendered.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 12 - INDEPENDENT REVIEW ORGANIZATIONS › Subchapter E - FEES AND PAYMENT › Section 12.402 - Classification of Specialty

Current through Reg. 49, No. 28; July 12, 2024
Fees for independent review will be based on a two-tiered
					 structure of specialty classifications as follows:
(1) Tier one fees will be for independent
				  review of medical or surgical care rendered by a doctor of medicine or doctor
				  of osteopathy.
(2) Tier two fees
				  will be for independent review of health care services rendered in the
				  specialties of podiatry, optometry, dental, audiology, speech-language
				  pathology, master social work, dietetics, professional counseling, psychology,
				  occupational therapy, physical therapy, marriage and family therapy,
				  chiropractic, and chemical dependency counseling, and any of their
				  subspecialties.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 12 - INDEPENDENT REVIEW ORGANIZATIONS › Subchapter E - FEES AND PAYMENT › Section 12.403 - Fee Amounts

Current through Reg. 49, No. 28; July 12, 2024
(a) Fees to be paid
				  to IROs by utilization review agents and other payors for each independent
				  review are as follows:
(1) tier one: $650;
				  and
(2) tier two: $460.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 12 - INDEPENDENT REVIEW ORGANIZATIONS › Subchapter E - FEES AND PAYMENT › Section 12.404 - Payment of Fees

Current through Reg. 49, No. 28; July 12, 2024
(a) IROs must bill
				  utilization review agents or payors, as appropriate, directly for fees for
				  independent review.
(b) IROs may
				  also bill utilization review agents or payors, as appropriate, for copy
				  expenses related to reviews as set out in §
										12.205
				  of this chapter.
(c) Utilization
				  review agents or payors, as appropriate, must pay IROs directly within 15 days
				  of receipt of invoice. For workers' compensation network and nonnetwork
				  disputes, the IRO fees must be paid under §
										133.308
				  of this title.
(d) Utilization
				  review agents may recover from the payors the costs associated with the
				  independent review.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 12 - INDEPENDENT REVIEW ORGANIZATIONS › Subchapter E - FEES AND PAYMENT › Section 12.405 - Failure To Pay Invoice

Current through Reg. 49, No. 28; July 12, 2024
Failure by utilization review agents or payors, as
					 appropriate, to pay invoices from an IRO within 15 days of receipt is a
					 violation of §
										12.404(c)
					 of this subchapter and subject to enforcement action and penalty under §
										12.302
					 of this chapter.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 12 - INDEPENDENT REVIEW ORGANIZATIONS › Subchapter E - FEES AND PAYMENT › Section 12.406 - Application and Renewal of Certificate of Registration Fees

Current through Reg. 49, No. 28; July 12, 2024
The fee to be paid to the department for the original
					 application for a certificate of registration as an IRO is $1000. The fee for
					 renewal of a certificate of registration is $400. There is no fee for reporting
					 a material change to a certificate of registration as an IRO.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 12 - INDEPENDENT REVIEW ORGANIZATIONS › Subchapter F - RANDOM ASSIGNMENT OF INDEPENDENT REVIEW ORGANIZATIONS › Section 12.501 - Requests for Independent Review

Current through Reg. 49, No. 28; July 12, 2024
Requests for independent review must be made to the
					 department on behalf of the patient by the utilization review agent under
					 Insurance Code Chapter 4201, Subchapter I and Chapter 19, Subchapters R and U
					 of this title; Chapter 10 of this title; Chapter 133 of this title; Chapter 134
					 of this title; or by a health insurance carrier, health maintenance
					 organization, or managed care entity under Civil Practice and Remedies Code
					 § 88.003(c).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 12 - INDEPENDENT REVIEW ORGANIZATIONS › Subchapter F - RANDOM ASSIGNMENT OF INDEPENDENT REVIEW ORGANIZATIONS › Section 12.502 - Random Assignment

Current through Reg. 49, No. 28; July 12, 2024
(a) The department
				  will randomly assign each request for independent review to an IRO and will
				  notify the utilization review agent and the health insurance carrier, health
				  maintenance organization, managed care entity, or other payor requesting the
				  independent review, the IRO, the patient or a representative of the patient,
				  and the provider of record of the assignment.
(b) The department will screen payors and
				  utilization review agents for potential conflicts of interest with the IRO
				  before making an assignment to the IRO. The IRO must screen its physicians and
				  other providers conducting independent review for potential conflicts of
				  interest. The department has the discretion to determine whether conflicts
				  exist.
(c) IROs will be added to
				  the list from which random assignments for independent reviews are made in
				  order of the date of issuance of the certificate of registration by the
				  department.
(d) The department will
				  randomly assign IROs chronologically from the list of IROs, with ultimate
				  assignment to the first in line with no apparent conflicts of
				  interest.
(e) Assignment of an
				  independent review to an IRO moves the IRO receiving the assignment to the
				  bottom of the assignment list.
(f)
				  Independent reviews will not be assigned:
(1)
				  to an IRO during the 30 days before the anniversary date of the issuance of the
				  IRO's certificate of registration unless the completed application for renewal
				  of its certificate of registration and the application fee have been received
				  by the department; or
(2) during
				  the time that an IRO has surrendered its certificate of registration under
				  §
											12.303
				  of this chapter and Insurance Code § 4202.002(c)(2)(B).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 12 - INDEPENDENT REVIEW ORGANIZATIONS › Subchapter G - EXEMPTIONS FOR INDEPENDENT REVIEW ORGANIZATIONS › Section 12.601 - Preauthorization Exemptions

Current through Reg. 49, No. 28; July 12, 2024
(a) In this
				  section, the following words and terms have the following meanings unless
				  context clearly indicates otherwise.
(1)
				  Adverse determination regarding a preauthorization exemption--Has the same
				  meaning as defined in § 19.1730 of this title (relating to
				  Definitions).
(2) Issuer--Has the
				  same meaning as defined in § 19.1730 of this title.
(3) Physician--Has the same meaning as
				  defined by Insurance Code §
											843.002, concerning
				  Definitions.
(4) Preauthorization
				  exemption--Has the same meaning as defined in § 19.1730 of this
				  title.
(5) Provider--Has the same
				  meaning as defined in Insurance Code §
											843.002.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 13 - MISCELLANEOUS INSURERS AND OTHER REGULATED ENTITIES › Subchapter A - STATEWIDE MUTUAL ASSESSMENT COMPANIES, LOCAL MUTUAL AID ASSOCIATIONS, AND BURIAL ASSOCIATIONS › Section 13.2 - Voting by Proxy

Current through Reg. 49, No. 28; July 12, 2024
Members may vote by proxy as provided by law, in accordance
					 with the bylaws and the terms of such proxies.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 13 - MISCELLANEOUS INSURERS AND OTHER REGULATED ENTITIES › Subchapter A - STATEWIDE MUTUAL ASSESSMENT COMPANIES, LOCAL MUTUAL AID ASSOCIATIONS, AND BURIAL ASSOCIATIONS › Section 13.3 - Policy Approval

Current through Reg. 49, No. 28; July 12, 2024
(a) Documents must
				  be submitted for approval.
(1) Forms must be
				  submitted in duplicate, completed as John Doe Specimen. Typewritten forms may
				  be submitted for preliminary review, but only printed forms will be accepted
				  for approval and filing.
(2) The
				  following forms are required to be submitted with each policy form:
(A) the application;
(B) the application for reinstatement;
				  and
(C) the rates to be used with
				  the policy.
(3) No
				  application, application for reinstatement, certificate, or policy of insurance
				  or schedule of rates to be used therewith shall be acted upon until all of such
				  items are in accordance with the Insurance Code and other applicable law, and
				  all of such items will be acted upon simultaneously.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 13 - MISCELLANEOUS INSURERS AND OTHER REGULATED ENTITIES › Subchapter A - STATEWIDE MUTUAL ASSESSMENT COMPANIES, LOCAL MUTUAL AID ASSOCIATIONS, AND BURIAL ASSOCIATIONS › Section 13.4 - Requirement of Certain Descriptive Words as a Part of the Corporate Name

Current through Reg. 49, No. 28; July 12, 2024
No company or association shall operate under a name that
					 is misleading or confusing to the public. A burial association shall include
					 the words "burial association" in its name.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 13 - MISCELLANEOUS INSURERS AND OTHER REGULATED ENTITIES › Subchapter A - STATEWIDE MUTUAL ASSESSMENT COMPANIES, LOCAL MUTUAL AID ASSOCIATIONS, AND BURIAL ASSOCIATIONS › Section 13.5 - Organization of a Local Mutual Aid Association or Local Mutual Burial Association

Current through Reg. 49, No. 28; July 12, 2024
There is no present rule on this subject. Licensees should
					 refer to statutory law.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 13 - MISCELLANEOUS INSURERS AND OTHER REGULATED ENTITIES › Subchapter A - STATEWIDE MUTUAL ASSESSMENT COMPANIES, LOCAL MUTUAL AID ASSOCIATIONS, AND BURIAL ASSOCIATIONS › Section 13.6 - Movement of Home Office

Current through Reg. 49, No. 28; July 12, 2024
There is no present rule on this subject. Licensees should
					 refer to statutory law.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 13 - MISCELLANEOUS INSURERS AND OTHER REGULATED ENTITIES › Subchapter A - STATEWIDE MUTUAL ASSESSMENT COMPANIES, LOCAL MUTUAL AID ASSOCIATIONS, AND BURIAL ASSOCIATIONS › Section 13.7 - Membership Fees

Current through Reg. 49, No. 28; July 12, 2024
(a) The following
				  are membership fee plans.
(1) Plan 1. The
				  first three monthly assessments may be stipulated as a membership fee and may
				  be placed in the expense fund. All other premiums or assessments shall be known
				  as regular premium assessments and shall be divided as follows.
(A) The regular premium assessments on all
				  life policies, including life coverages in accident and health policies, shall
				  be divided so as to place an amount at least equal to the renewal net premium
				  in the mortuary fund in accordance with approved statutory reserve standards
				  adopted by the company or association. All other portions of the premiums or
				  assessments may be placed in the expense fund. All policy claims may be paid
				  out of the mortuary fund.
(B) The
				  regular premium assessments on all health, accident, accidental death,
				  sickness, and hospitalization policies shall be divided so that at least 60% of
				  such premiums shall be placed in the mortuary fund of the company or
				  association. All other portions of the premiums or assessments may be placed in
				  the expense fund. All policy claims may be paid out of the mortuary
				  fund.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 13 - MISCELLANEOUS INSURERS AND OTHER REGULATED ENTITIES › Subchapter A - STATEWIDE MUTUAL ASSESSMENT COMPANIES, LOCAL MUTUAL AID ASSOCIATIONS, AND BURIAL ASSOCIATIONS › Section 13.8 - Operation and Management of Companies and Associations

Current through Reg. 49, No. 28; July 12, 2024
(a) The board finds and declares that mutual
				  assessment companies, local mutual aid associations and burial associations
				  shall operate in the following manner and under the following conditions.
(1) The operation of such companies shall be
				  mutual in character.
(2) The
				  operation of such companies shall be on a nonprofit basis.
(3) The board of directors of the company
				  shall maintain its control over the operations of such company and shall not
				  divest itself of its duties and responsibilities to manage the affairs of such
				  company for the benefit of the policyholders or members thereof.
(4) The board of directors of the company
				  shall determine the amount of compensation to be paid to officers, directors,
				  employees, agents, and managers, which compensation shall be reasonable and
				  shall be only for personal services rendered and reimbursement for actual and
				  necessary expenses incurred, and the board of directors shall also fix and
				  determine the length of time such officers, directors, employees, agents and
				  managers shall be so engaged and compensated.
(5) Any employment, general agency or general
				  manager contract with the company shall have a reasonable cancellation
				  provision whereby either the company or the employee, general agent, or general
				  manager may cancel such contract for good cause.
(6) All persons who hold a general management
				  or general agency contract and perform any services or functions thereunder,
				  shall be bonded in an amount not less than that required of an officer
				  responsible for the handling of funds.
(7) No officer, director, agent, manager or
				  employee of a company shall pay or receive, directly or indirectly, for his
				  personal use or benefit, anything of value as consideration or partial
				  consideration for the resignation or election of an officer or director of any
				  such company, or for transferring or assigning proxies or appointing a
				  substitute in connection with any proxies, or for the sale of any asset of
				  whatever kind or character belonging to such company or association.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 13 - MISCELLANEOUS INSURERS AND OTHER REGULATED ENTITIES › Subchapter A - STATEWIDE MUTUAL ASSESSMENT COMPANIES, LOCAL MUTUAL AID ASSOCIATIONS, AND BURIAL ASSOCIATIONS › Section 13.10 - Merger under the Insurance Code, Article 14.13

Current through Reg. 49, No. 28; July 12, 2024
(a) No association or company shall merge
				  with another association or company nor transfer any part or group of its
				  membership to another association or company nor merge nor transfer members
				  from one group to another within an association or company without first
				  obtaining the consent of the commissioner of insurance. The commissioner of
				  insurance may not consent to any such merger or transfer except after a
				  complete investigation into the facts and a determination by him that such
				  transfer or merger is to the advantage of the association or company or groups
				  to be affected.
(b) In effecting
				  such merger or transfer, the provisions of the Texas Nonprofit Corporation Act
				  shall be followed to the extent that such provisions are applicable and such
				  duties as are required of the secretary of state under such Act shall be
				  performed by the commissioner of insurance.
(c) The commissioner of insurance may
				  consider, among other things, the following:
(1) whether such merger or transfer was duly
				  authorized in accordance with the articles of association or articles of
				  incorporation of the respective associations or companies and in accordance
				  with the bylaws of the respective associations or companies;
(2) whether such merger or transfer was duly
				  authorized in accordance with the provisions of the Texas Nonprofit Corporation
				  Act and other applicable statutes and in conformity with the applicable rules
				  of the State Board of Insurance;
(3) the minutes of the respective membership
				  and boards of directors' meetings concerning such merger and whether such
				  minutes contain the text of the resolutions and motions adopted and a
				  tabulation of votes upon each motion and resolution;
(4) the terms of the plan of
				  merger;
(5) the terms of the
				  articles of merger;
(6) the terms
				  of the certificate of assumption or other certificate which is proposed to be
				  issued to the members being transferred;
(7) the financial condition of each
				  association or company and of each group, club, or class affected by such
				  merger, including a statement setting forth the number of members and amount of
				  assets and liabilities of each fund being transferred;
(8) such statements as are required under the
				  provisions of the Texas Nonprofit Corporation Act, Article 5.04;
(9) if, under the terms of the merger, all of
				  the members of an association or company are being transferred, whether such
				  association has surrendered for cancellation its articles of association or
				  articles of incorporation, its constitution and bylaws and its current
				  certificate of authority.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 13 - MISCELLANEOUS INSURERS AND OTHER REGULATED ENTITIES › Subchapter A - STATEWIDE MUTUAL ASSESSMENT COMPANIES, LOCAL MUTUAL AID ASSOCIATIONS, AND BURIAL ASSOCIATIONS › Section 13.11 - Status of Exempt Associations

Current through Reg. 49, No. 28; July 12, 2024
There is no present rule on this subject. Licensees should
					 refer to statutory law.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 13 - MISCELLANEOUS INSURERS AND OTHER REGULATED ENTITIES › Subchapter A - STATEWIDE MUTUAL ASSESSMENT COMPANIES, LOCAL MUTUAL AID ASSOCIATIONS, AND BURIAL ASSOCIATIONS › Section 13.12 - Assessments and Rate Schedules

Current through Reg. 49, No. 28; July 12, 2024
(a) All rate
				  schedules to be used by a company or association shall be first adopted in
				  accordance with the bylaws or articles of association of such company or
				  association and shall be submitted in duplicate to the State Board of Insurance
				  prior to the use of such rates.
(b)
				  All rate schedules to be used by a company or association shall be file-marked
				  by the State Board of Insurance and a duplicate copy forwarded to the company
				  or association. Each company or association shall maintain the file-marked copy
				  in its permanent files.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 13 - MISCELLANEOUS INSURERS AND OTHER REGULATED ENTITIES › Subchapter A - STATEWIDE MUTUAL ASSESSMENT COMPANIES, LOCAL MUTUAL AID ASSOCIATIONS, AND BURIAL ASSOCIATIONS › Section 13.13 - The Use of Mortuary Funds for the Purpose of Defending Contested Claims

Current through Reg. 49, No. 28; July 12, 2024
There is no present rule on this subject. Licensees should
					 refer to statutory law.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 13 - MISCELLANEOUS INSURERS AND OTHER REGULATED ENTITIES › Subchapter A - STATEWIDE MUTUAL ASSESSMENT COMPANIES, LOCAL MUTUAL AID ASSOCIATIONS, AND BURIAL ASSOCIATIONS › Section 13.14 - Ownership and Investment of Assets

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  Ownership of assets.
(1) No company or
				  association funds may be disbursed for the purpose of purchasing or investing
				  in any asset unless such asset thereby becomes the property of the fund from
				  which the disbursement is made, but this requirement shall not prohibit an
				  unequivocal transfer to the mortuary fund from the expense fund.
(2) No company or association may permit any
				  asset belonging to such company or association to be held, registered, or
				  deposited in any name other than that of the fund and company or association
				  owning such asset.
(3) Each company
				  or association shall at all times have direct control and supervision over each
				  asset owned by such company or association.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 13 - MISCELLANEOUS INSURERS AND OTHER REGULATED ENTITIES › Subchapter A - STATEWIDE MUTUAL ASSESSMENT COMPANIES, LOCAL MUTUAL AID ASSOCIATIONS, AND BURIAL ASSOCIATIONS › Section 13.15 - Beneficiaries under Burial Policies

Current through Reg. 49, No. 28; July 12, 2024
There is no present rule on this subject except §
										13.3(c)(3)(B)
					 of this title (relating to Policy Approval). Licensees should refer to
					 statutory law.