CHAPTER 4201. UTILIZATION REVIEW AGENTS
INSURANCE CODE
TITLE 14. UTILIZATION REVIEW AND INDEPENDENT REVIEW
CHAPTER 4201. UTILIZATION REVIEW AGENTS
SUBCHAPTER A. GENERAL PROVISIONS
Sec. 4201.001. PURPOSE. The purpose of this chapter is to:
(1) promote the delivery of quality health care in a
cost-effective manner;
(2) ensure that a utilization review agent adheres to reasonable
standards for conducting utilization review;
(3) foster greater coordination and cooperation between a health
care provider and utilization review agent;
(4) improve communications and knowledge of benefits among all
parties concerned before an expense is incurred; and
(5) ensure that a utilization review agent maintains the
confidentiality of medical records in accordance with applicable
law.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4201.002. DEFINITIONS. In this chapter:
(1) "Adverse determination" means a determination by a
utilization review agent that health care services provided or
proposed to be provided to a patient are not medically necessary
or are experimental or investigational.
(2) "Emergency care" means health care services provided in a
hospital emergency facility or comparable facility to evaluate
and stabilize medical conditions of a recent onset and severity,
including severe pain, that would lead a prudent layperson
possessing an average knowledge of medicine and health to believe
that the individual's condition, sickness, or injury is of such a
nature that failure to get immediate medical care could:
(A) place the individual's health in serious jeopardy;
(B) result in serious impairment to bodily functions;
(C) result in serious dysfunction of a bodily organ or part;
(D) result in serious disfigurement; or
(E) for a pregnant woman, result in serious jeopardy to the
health of the fetus.
(3) "Enrollee" means an individual covered by a health
insurance policy or health benefit plan. The term includes an
individual who is covered as an eligible dependent of another
individual.
(4) "Health benefit plan" means a plan of benefits, other than a
health insurance policy, that:
(A) defines the coverage provisions for health care for
enrollees; and
(B) is offered or provided by a public or private organization.
(5) "Health care provider" means a person, corporation,
facility, or institution that is:
(A) licensed by a state to provide or is otherwise lawfully
providing health care services; and
(B) eligible for independent reimbursement for those health care
services.
(6) "Health insurance policy" means an insurance policy,
including a policy written by a corporation subject to Chapter
842, that provides coverage for medical or surgical expenses
incurred as a result of accident or sickness.
(7) "Life-threatening" means a disease or condition from which
the likelihood of death is probable unless the course of the
disease or condition is interrupted.
(8) "Nurse" means a professional or registered nurse, a licensed
vocational nurse, or a licensed practical nurse.
(9) "Patient" means the enrollee or an eligible dependent of the
enrollee under a health benefit plan or health insurance policy.
(10) "Payor" means:
(A) an insurer that writes health insurance policies;
(B) a preferred provider organization, health maintenance
organization, or self-insurance plan; or
(C) any other person or entity that provides, offers to provide,
or administers hospital, outpatient, medical, or other health
benefits to a person treated by a health care provider in this
state under a policy, plan, or contract.
(11) "Physician" means a licensed doctor of medicine or a doctor
of osteopathy.
(12) "Provider of record" means the physician or other health
care provider with primary responsibility for the care,
treatment, and services provided to an enrollee. The term
includes a health care facility if treatment is provided on an
inpatient or outpatient basis.
(13) "Utilization review" includes a system for prospective,
concurrent, or retrospective review of the medical necessity and
appropriateness of health care services and a system for
prospective, concurrent, or retrospective review to determine the
experimental or investigational nature of health care services.
The term does not include a review in response to an elective
request for clarification of coverage.
(14) "Utilization review agent" means an entity that conducts
utilization review for:
(A) an employer with employees in this state who are covered
under a health benefit plan or health insurance policy;
(B) a payor; or
(C) an administrator holding a certificate of authority under
Chapter 4151.
(15) "Utilization review plan" means the screening criteria and
utilization review procedures of a utilization review agent.
(16) "Working day" means a weekday that is not a legal holiday.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Amended by:
Acts 2009, 81st Leg., R.S., Ch.
1330, Sec. 7, eff. September 1, 2009.
Sec. 4201.003. RULES. (a) The commissioner may adopt rules to
implement this chapter.
(b) A rule adopted under this chapter relates only to a person
or entity subject to this chapter.
(c) The commissioner shall appoint an advisory committee to
advise the commissioner on development of rules regarding the
administration of this chapter, as authorized by Section
2001.031, Government Code. The committee includes:
(1) the public counsel appointed under Chapter 501; and
(2) one representative for each of the following:
(A) insurers;
(B) health maintenance organizations;
(C) group hospital service corporations;
(D) utilization review agents;
(E) employers;
(F) consumer organizations;
(G) physicians;
(H) dentists;
(I) hospitals;
(J) registered nurses; and
(K) other health care providers.
(d) The advisory committee's deliberations are subject to
Chapter 551, Government Code.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4201.004. TELEPHONE ACCESS. (a) A utilization review
agent shall:
(1) have appropriate personnel reasonably available, by
toll-free telephone at least 40 hours per week during normal
business hours in this state, to discuss patients' care and allow
response to telephone review requests;
(2) have a telephone system capable, during hours other than
normal business hours, of accepting or recording incoming
telephone calls or of providing instructions to a caller; and
(3) respond to a call made during hours other than normal
business hours not later than the second working day after the
later of:
(A) the date the call was received; or
(B) the date the details necessary to respond have been received
from the caller.
(b) A utilization review agent must provide to the commissioner
a written description of the procedures to be used when
responding with respect to poststabilization care subsequent to
emergency treatment as requested by a treating physician or other
health care provider.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
SUBCHAPTER B. APPLICABILITY OF CHAPTER
Sec. 4201.051. PERSONS PROVIDING INFORMATION ABOUT SCOPE OF
COVERAGE OR BENEFITS. This chapter does not apply to a person
who:
(1) provides information to an enrollee about scope of coverage
or benefits provided under a health insurance policy or health
benefit plan; and
(2) does not determine whether a particular health care service
provided or to be provided to an enrollee is:
(A) medically necessary or appropriate; or
(B) experimental or investigational.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Amended by:
Acts 2009, 81st Leg., R.S., Ch.
1330, Sec. 8, eff. September 1, 2009.
Sec. 4201.052. CERTAIN CONTRACTS WITH FEDERAL GOVERNMENT. This
chapter does not apply to a contract with the federal government
to provide utilization review with respect to a patient who is
eligible for services under Title XVIII or XIX of the Social
Security Act (42 U.S.C. Section 1395 et seq. or Section 1396 et
seq.).
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4201.053. MEDICAID AND CERTAIN OTHER STATE HEALTH OR MENTAL
HEALTH PROGRAMS. Except as provided by Section 4201.057, this
chapter does not apply to:
(1) the state Medicaid program;
(2) the services program for children with special health care
needs under Chapter 35, Health and Safety Code;
(3) a program administered under Title 2, Human Resources Code;
(4) a program of the Department of State Health Services
relating to mental health services;
(5) a program of the Department of Aging and Disability Services
relating to mental retardation services; or
(6) a program of the Texas Department of Criminal Justice.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4201.054. WORKERS' COMPENSATION BENEFITS. (a) Except as
provided by this section, this chapter applies to utilization
review of a health care service provided to a person eligible for
workers' compensation medical benefits under Title 5, Labor Code.
The commissioner of workers' compensation shall regulate as
provided by this chapter a person who performs utilization review
of a medical benefit provided under Title 5, Labor Code.
(b) Repealed by Acts 2007, 80th Leg., R.S., Ch. 730, Sec.
3B.075(b), eff. September 1, 2007.
(c) Title 5, Labor Code, prevails in the event of a conflict
between this chapter and Title 5, Labor Code.
(d) The commissioner of workers' compensation may adopt rules as
necessary to implement this section.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Amended by:
Acts 2007, 80th Leg., R.S., Ch.
134, Sec. 7(a), eff. September 1, 2007.
Acts 2007, 80th Leg., R.S., Ch.
134, Sec. 7(b), eff. September 1, 2007.
Acts 2007, 80th Leg., R.S., Ch.
730, Sec. 3B.075(a), eff. September 1, 2007.
Acts 2007, 80th Leg., R.S., Ch.
730, Sec. 3B.075(b), eff. September 1, 2007.
Acts 2007, 80th Leg., R.S., Ch.
921, Sec. 9.075(a), eff. September 1, 2007.
Acts 2007, 80th Leg., R.S., Ch.
921, Sec. 9.075(b), eff. September 1, 2007.
Sec. 4201.055. HEALTH CARE SERVICE PROVIDED UNDER AUTOMOBILE
INSURANCE POLICY. This chapter does not apply to utilization
review of a health care service provided under an automobile
insurance policy or contract that is authorized under Chapter
2301 or Article 5.13-2 or that is issued under Chapter 981.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4201.056. EMPLOYEE WELFARE BENEFIT PLANS. This chapter
does not apply to the terms or benefits of an employee welfare
benefit plan defined by Section 3(1) of the Employee Retirement
Income Security Act of 1974 (29 U.S.C. Section 1002(1)).
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4201.057. HEALTH MAINTENANCE ORGANIZATIONS. (a) In this
section, "health maintenance organization" includes a health
maintenance organization that contracts with the Health and Human
Services Commission or with an agency operating part of the state
Medicaid managed care program to provide health care services to
recipients of medical assistance under Chapter 32, Human
Resources Code.
(b) This chapter applies to a health maintenance organization
except as expressly provided by this section.
(c) As a condition of holding a certificate of authority to
engage in the business of a health maintenance organization, a
health maintenance organization that performs utilization review
must:
(1) comply with this chapter, except Subchapter C; and
(2) submit to assessment of a maintenance tax under Chapter 258
to cover the costs of administering compliance with this
subsection.
(d) The commissioner shall adopt rules for appropriate
verification and enforcement of compliance with Subsection (c).
(e) Notwithstanding Subsection (c)(1), a health maintenance
organization that performs utilization review for a person or
entity subject to this chapter, other than a person or entity for
which the health maintenance organization is the payor, must
obtain a certificate of registration under Subchapter C and shall
comply with all of the provisions of this chapter.
(f) This chapter does not prohibit or limit the distribution of
a portion of the savings from the reduction or elimination of
unnecessary medical services, treatment, supplies, confinements,
or days of confinement in a health care facility through profit
sharing, bonus, or withholding arrangements to a participating
physician or participating health care provider for providing
health care services to an enrollee.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4201.058. INSURERS. (a) This chapter applies to an
insurer subject to this code that delivers or issues for delivery
a health insurance policy in this state except as expressly
provided by this section. As a condition of holding a
certificate of authority to engage in the business of insurance,
an insurer that performs utilization review shall comply with
this chapter, except Subchapter C. The insurer is subject to
assessment of a maintenance tax under Chapter 257 to cover the
costs of administering compliance with this subsection.
(b) The commissioner shall adopt rules for appropriate
verification and enforcement of compliance with Subsection (a).
(c) Notwithstanding Subsection (a), an insurer subject to this
code that performs utilization review for a person or entity
subject to this chapter, other than a person or entity for which
the insurer is the payor, must obtain a certificate of
registration under Subchapter C and shall comply with all of the
provisions of this chapter.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
SUBCHAPTER C. CERTIFICATION
Sec. 4201.101. CERTIFICATE OF REGISTRATION REQUIRED. A
utilization review agent may not conduct utilization review
unless the commissioner issues a certificate of registration to
the agent under this subchapter.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4201.102. REQUIREMENTS FOR CERTIFICATION. (a) The
commissioner may issue a certificate of registration only to an
applicant who has met all the requirements of this chapter and
all applicable rules adopted by the commissioner.
(b) As a condition of holding a certificate of registration or
renewal of a certificate, a utilization review agent must
maintain compliance with Subchapters D, E, and F.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4201.103. CERTIFICATE RENEWAL. Certification may be
renewed biennially by filing, not later than March 1, a renewal
form with the commissioner accompanied by a fee in an amount set
by the commissioner.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4201.104. CERTIFICATION AND RENEWAL FORMS. (a) The
commissioner shall promulgate forms to be filed under this
subchapter for initial certification and for a renewal
certificate of registration. The form for initial certification
must require:
(1) the utilization review agent's name, address, telephone
number, and normal business hours;
(2) the name and address of an agent for service of process in
this state;
(3) a summary of the utilization review plan;
(4) information concerning the categories of personnel who will
perform utilization review for the agent;
(5) a copy of the procedures established under Subchapter H for
the appeal of an adverse determination;
(6) a certification that the agent will comply with this
chapter; and
(7) a copy of the procedures for resolving oral or written
complaints initiated by enrollees, patients, or health care
providers as required by Section 4201.204.
(b) The commissioner may not require that the summary of the
utilization review plan include proprietary details.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4201.105. FEES. The commissioner shall establish,
administer, and enforce the fees for initial certification and
certification renewal in amounts that do not exceed the amounts
necessary to cover the cost of administering this chapter.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4201.106. CERTIFICATE NOT TRANSFERABLE. A certificate of
registration is not transferable.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4201.107. REPORTING MATERIAL CHANGES. A utilization review
agent shall report any material change to the information
disclosed in a form filed under this subchapter not later than
the 30th day after the date the change takes effect.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4201.108. LIST OF UTILIZATION REVIEW AGENTS. (a) The
commissioner shall maintain and update monthly a list of each
utilization review agent to whom a certificate of registration
has been issued and the renewal date of the certificate.
(b) The commissioner shall provide the list at cost to each
individual or organization requesting the list.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
SUBCHAPTER D. UTILIZATION REVIEW: GENERAL STANDARDS
Sec. 4201.151. UTILIZATION REVIEW PLAN. A utilization review
agent's utilization review plan, including reconsideration and
appeal requirements, must be reviewed by a physician and
conducted in accordance with standards developed with input from
appropriate health care providers and approved by a physician.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4201.152. UTILIZATION REVIEW UNDER DIRECTION OF PHYSICIAN.
A utilization review agent shall conduct utilization review under
the direction of a physician licensed to practice medicine by a
state licensing agency in the United States.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4201.153. SCREENING CRITERIA AND REVIEW PROCEDURES. (a) A
utilization review agent shall use written medically acceptable
screening criteria and review procedures that are established and
periodically evaluated and updated with appropriate involvement
from physicians, including practicing physicians, dentists, and
other health care providers.
(b) A utilization review determination shall be made in
accordance with currently accepted medical or health care
practices, taking into account special circumstances of the case
that may require deviation from the norm stated in the screening
criteria.
(c) Screening criteria must be:
(1) objective;
(2) clinically valid;
(3) compatible with established principles of health care; and
(4) flexible enough to allow a deviation from the norm when
justified on a case-by-case basis.
(d) Screening criteria must be used to determine only whether to
approve the requested treatment. A denial of requested treatment
must be referred to an appropriate physician, dentist, or other
health care provider to determine medical necessity.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4201.154. REVIEW AND INSPECTION OF SCREENING CRITERIA AND
REVIEW PROCEDURES. (a) A utilization review agent's written
screening criteria and review procedures shall be made available
for:
(1) review and inspection to determine appropriateness and
compliance as considered necessary by the commissioner; and
(2) copying as necessary for the commissioner to accomplish the
commissioner's duties under this code.
(b) Any information obtained or acquired under the authority of
this section, Section 4201.153, and this chapter is confidential
and privileged and is not subject to Chapter 552, Government
Code, or to subpoena except to the extent necessary for the
commissioner to enforce this chapter.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4201.155. LIMITATION ON NOTICE REQUIREMENTS AND REVIEW
PROCEDURES. A utilization review agent may not establish or
impose a notice requirement or other review procedure that is
contrary to the requirements of the health insurance policy or
health benefit plan.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
SUBCHAPTER E. UTILIZATION REVIEW: RELATIONS WITH PATIENTS AND
HEALTH CARE PROVIDERS
Sec. 4201.201. REPETITIVE CONTACTS WITH HEALTH CARE PROVIDER OR
PATIENT; FREQUENCY OF REVIEWS. A utilization review agent:
(1) may not engage in unnecessary or unreasonable repetitive
contacts with a health care provider or patient; and
(2) shall base the frequency of contacts or reviews on the
severity or complexity of the patient's condition or on necessary
treatment and discharge planning activity.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4201.202. OBSERVING OR PARTICIPATING IN PATIENT'S CARE.
(a) Unless approved for an individual patient by the provider of
record or modified by contract, a utilization review agent shall
be prohibited from observing, participating in, or otherwise
being present during a patient's examination, treatment,
procedure, or therapy.
(b) This subchapter, Subchapters D and F, and Section
4201.102(b) may not be construed to otherwise limit or deny
contact with a patient for purposes of conducting utilization
review unless otherwise specifically prohibited by law.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4201.203. MENTAL HEALTH THERAPY. (a) A utilization review
agent may not require, as a condition of treatment approval or
for any other reason, the observation of a psychotherapy session
or the submission or review of a mental health therapist's
process or progress notes.
(b) Notwithstanding this section, a utilization review agent may
require submission of a patient's medical record summary.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4201.204. COMPLAINT SYSTEM. (a) A utilization review
agent shall establish and maintain a complaint system that
provides reasonable procedures for the resolution of oral or
written complaints initiated by enrollees, patients, or health
care providers concerning the utilization review.
(b) The complaint procedure must include a requirement that the
utilization review agent provide a written response to the
complainant within 30 days.
(c) A utilization review agent shall submit to the commissioner
a summary report of all complaints at the times and in the form
specified by the commissioner. The agent shall allow the
commissioner to examine the complaints and relevant documents at
any time.
(d) A utilization review agent shall maintain a record of each
complaint until the third anniversary of the date the complainant
filed the complaint.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4201.205. DESIGNATED INITIAL CONTACT. (a) A health care
provider may designate one or more individuals as the initial
contact or contacts for a utilization review agent seeking
routine information or data.
(b) A designation made under this section may not preclude a
utilization review agent or medical advisor from contacting a
health care provider or the provider's employees who are not
designated under this section under circumstances in which:
(1) a review might otherwise be unreasonably delayed; or
(2) the designated individual is unable to provide the necessary
data or information that the agent requests.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4201.206. OPPORTUNITY TO DISCUSS TREATMENT BEFORE ADVERSE
DETERMINATION. Subject to the notice requirements of Subchapter
G, before an adverse determination is issued by a utilization
review agent who questions the medical necessity or
appropriateness, or the experimental or investigational nature,
of a health care service, the agent shall provide the health care
provider who ordered the service a reasonable opportunity to
discuss with a physician the patient's treatment plan and the
clinical basis for the agent's determination.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Amended by:
Acts 2009, 81st Leg., R.S., Ch.
1330, Sec. 9, eff. September 1, 2009.
Sec. 4201.207. CHARGES BY HEALTH CARE PROVIDER FOR PROVIDING
MEDICAL INFORMATION. (a) Unless precluded or modified by
contract, a utilization review agent shall reimburse a health
care provider for the reasonable costs of providing medical
information in writing, including the costs of copying and
transmitting requested patient records or other documents.
(b) A health care provider's charges for providing medical
information to a utilization review agent may not:
(1) exceed the cost of copying records regarding a workers'
compensation claim as set by rules adopted by the commissioner of
workers' compensation; or
(2) include any costs otherwise recouped as part of the charges
for health care.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Amended by:
Acts 2007, 80th Leg., R.S., Ch.
134, Sec. 8(a), eff. September 1, 2007.
Acts 2007, 80th Leg., R.S., Ch.
730, Sec. 3B.076(a), eff. September 1, 2007.
Acts 2007, 80th Leg., R.S., Ch.
921, Sec. 9.076(a), eff. September 1, 2007.
SUBCHAPTER F. UTILIZATION REVIEW: PERSONNEL
Sec. 4201.251. DELEGATION OF UTILIZATION REVIEW. A utilization
review agent may delegate utilization review to qualified
personnel in the hospital or other health care facility in which
the health care services to be reviewed were or are to be
provided. The delegation does not release the agent from the
full responsibility for compliance with this chapter, including
the conduct of those to whom utilization review has been
delegated.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4201.252. PERSONNEL. (a) Personnel employed by or under
contract with a utilization review agent to perform utilization
review must be appropriately trained and qualified.
(b) Personnel, other than a physician, who obtain oral or
written information directly from a patient's physician or other
health care provider regarding the patient's specific medical
condition, diagnosis, or treatment options or protocols must be a
nurse, physician assistant, or other health care provider
qualified to provide the requested service.
(c) This section may not be interpreted to require personnel who
perform clerical or administrative tasks to have the
qualifications prescribed by this section.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4201.253. PROHIBITED BASES FOR EMPLOYMENT, COMPENSATION,
EVALUATIONS, OR PERFORMANCE STANDARDS. A utilization review
agent may not permit or provide compensation or another thing of
value to an employee or agent of the utilization review agent,
condition employment of the agent's employees or agent
evaluations, or set employee or agent performance standards,
based on the amount of volume of adverse determinations,
reductions of or limitations on lengths of stay, benefits,
services, or charges, or the number or frequency of telephone
calls or other contacts with health care providers or patients,
that are inconsistent with this chapter.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
SUBCHAPTER G. NOTICE OF DETERMINATIONS
Sec. 4201.301. GENERAL DUTY TO NOTIFY. A utilization review
agent shall provide notice of a determination made in a
utilization review to:
(1) the enrollee's provider of record; and
(2) the enrollee or a person acting on the enrollee's behalf.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4201.302. GENERAL TIME FOR NOTICE. A utilization review
agent must mail or otherwise transmit the notice required by this
subchapter not later than the second working day after the date
of the request for utilization review and the agent receives all
information necessary to complete the review.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4201.303. ADVERSE DETERMINATION: CONTENTS OF NOTICE. (a)
Notice of an adverse determination must include:
(1) the principal reasons for the adverse determination;
(2) the clinical basis for the adverse determination;
(3) a description of or the source of the screening criteria
used as guidelines in making the adverse determination; and
(4) a description of the procedure for the complaint and appeal
process, including notice to the enrollee of the enrollee's right
to appeal an adverse determination to an independent review
organization and of the procedures to obtain that review.
(b) For an enrollee who has a life-threatening condition, the
notice required by Subsection (a)(4) must include a description
of the enrollee's right to an immediate review by an independent
review organization and of the procedures to obtain that review.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4201.304. TIME FOR NOTICE OF ADVERSE DETERMINATION. A
utilization review agent shall provide notice of an adverse
determination required by this subchapter as follows:
(1) with respect to a patient who is hospitalized at the time of
the adverse determination, within one working day by either
telephone or electronic transmission to the provider of record,
followed by a letter within three working days notifying the
patient and the provider of record of the adverse determination;
(2) with respect to a patient who is not hospitalized at the
time of the adverse determination, within three working days in
writing to the provider of record and the patient; or
(3) within the time appropriate to the circumstances relating to
the delivery of the services to the patient and to the patient's
condition, provided that when denying poststabilization care
subsequent to emergency treatment as requested by a treating
physician or other health care provider, the agent shall provide
the notice to the treating physician or other health care
provider not later than one hour after the time of the request.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4201.305. NOTICE OF ADVERSE DETERMINATION FOR RETROSPECTIVE
UTILIZATION REVIEW. (a) Notwithstanding Sections 4201.302 and
4201.304, if a retrospective utilization review is conducted, the
utilization review agent shall provide notice of an adverse
determination under the retrospective utilization review in
writing to the provider of record and the patient within a
reasonable period, but not later than 30 days after the date on
which the claim is received.
(b) The period under Subsection (a) may be extended once by the
utilization review agent for a period not to exceed 15 days, if
the utilization review agent:
(1) determines that an extension is necessary due to matters
beyond the utilization review agent's control; and
(2) notifies the provider of record and the patient before the
expiration of the initial 30-day period of the circumstances
requiring the extension and the date by which the utilization
review agent expects to make a determination.
(c) If the extension under Subsection (b) is required because of
the failure of the provider of record or the patient to submit
information necessary to reach a determination on the request,
the notice of extension must:
(1) specifically describe the required information necessary to
complete the request; and
(2) give the provider of record and the patient at least 45 days
from the date of receipt of the notice of extension to provide
the specified information.
(d) If the period for making the determination under this
section is extended because of the failure of the provider of
record or the patient to submit the information necessary to make
the determination, the period for making the determination is
tolled from the date on which the utilization review agent sends
the notification of the extension to the provider of record or
the patient until the earlier of:
(1) the date on which the provider of record or the patient
responds to the request for additional information; or
(2) the date by which the specified information was to have been
submitted.
(e) If the periods for retrospective utilization review provided
by this section conflict with the time limits concerning or
related to payment of claims established under Subchapter J,
Chapter 843, the time limits established under Subchapter J,
Chapter 843, control.
(f) If the periods for retrospective utilization review provided
by this section conflict with the time limits concerning or
related to payment of claims established under Subchapters C and
C-1, Chapter 1301, the time limits established under Subchapters
C and C-1, Chapter 1301, control.
(g) If the periods for retrospective utilization review provided
by this section conflict with the time limits concerning or
related to payment of claims established under Section 408.027,
Labor Code, the time limits established under Section 408.027,
Labor Code, control.
Added by Acts 2009, 81st Leg., R.S., Ch.
1330, Sec. 10, eff. September 1, 2009.
SUBCHAPTER H. APPEAL OF ADVERSE DETERMINATION
Sec. 4201.351. COMPLAINT AS APPEAL. For purposes of this
subchapter, a complaint filed concerning dissatisfaction or
disagreement with an adverse determination constitutes an appeal
of that adverse determination.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4201.352. WRITTEN DESCRIPTION OF APPEAL PROCEDURES. A
utilization review agent shall maintain and make available a
written description of the procedures for appealing an adverse
determination.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4201.353. APPEAL PROCEDURES MUST BE REASONABLE. The
procedures for appealing an adverse determination must be
reasonable.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4201.354. PERSONS OR ENTITIES WHO MAY APPEAL. The
procedures for appealing an adverse determination must provide
that the adverse determination may be appealed orally or in
writing by:
(1) an enrollee;
(2) a person acting on the enrollee's behalf; or
(3) the enrollee's physician or other health care provider.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4201.355. ACKNOWLEDGMENT OF APPEAL. (a) The procedures
for appealing an adverse determination must provide that, within
five working days from the date the utilization review agent
receives the appeal, the agent shall send to the appealing party
a letter acknowledging the date of receipt.
(b) The letter must also include a list of:
(1) the procedures required by this subchapter; and
(2) the documents that the appealing party must submit for
review.
(c) When a utilization review agent receives an oral appeal of
an adverse determination, the agent shall send a one-page appeal
form to the appealing party.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4201.356. DECISION BY PHYSICIAN REQUIRED; SPECIALTY REVIEW.
(a) The procedures for appealing an adverse determination must
provide that a physician makes the decision on the appeal, except
as provided by Subsection (b).
(b) If not later than the 10th working day after the date an
appeal is denied the enrollee's health care provider states in
writing good cause for having a particular type of specialty
provider review the case, a health care provider who is of the
same or a similar specialty as the health care provider who would
typically manage the medical or dental condition, procedure, or
treatment under consideration for review shall review the
decision denying the appeal. The specialty review must be
completed within 15 working days of the date the health care
provider's request for specialty review is received.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4201.357. EXPEDITED APPEAL FOR DENIAL OF EMERGENCY CARE OR
CONTINUED HOSPITALIZATION. (a) The procedures for appealing an
adverse determination must include, in addition to the written
appeal, a procedure for an expedited appeal of a denial of
emergency care or a denial of continued hospitalization. That
procedure must include a review by a health care provider who:
(1) has not previously reviewed the case; and
(2) is of the same or a similar specialty as the health care
provider who would typically manage the medical or dental
condition, procedure, or treatment under review in the appeal.
(b) The time for resolution of an expedited appeal under this
section shall be based on the medical or dental immediacy of the
condition, procedure, or treatment under review, provided that
the resolution of the appeal may not exceed one working day from
the date all information necessary to complete the appeal is
received.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4201.358. RESPONSE LETTER TO INTERESTED PERSONS. The
procedures for appealing an adverse determination must provide
that, after the utilization review agent has sought review of the
appeal, the agent shall issue a response letter explaining the
resolution of the appeal to:
(1) the patient or a person acting on the patient's behalf; and
(2) the patient's physician or other health care provider.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4201.359. NOTICE OF APPEAL. (a) The procedures for
appealing an adverse determination must require written notice to
the appealing party of the determination of the appeal as soon as
practicable, but not later than the 30th calendar day, after the
date the utilization review agent receives the appeal.
(b) If the appeal is denied, the notice must include a clear and
concise statement of:
(1) the clinical basis for the denial;
(2) the specialty of the physician or other health care provider
making the denial; and
(3) the appealing party's right to seek review of the denial by
an independent review organization under Subchapter I and the
procedures for obtaining that review.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4201.360. IMMEDIATE APPEAL TO INDEPENDENT REVIEW
ORGANIZATION IN LIFE-THREATENING CIRCUMSTANCES. Notwithstanding
any other law, in a circumstance involving an enrollee's
life-threatening condition, the enrollee is:
(1) entitled to an immediate appeal to an independent review
organization as provided by Subchapter I; and
(2) not required to comply with procedures for an internal
review of the utilization review agent's adverse determination.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
SUBCHAPTER I. INDEPENDENT REVIEW OF ADVERSE DETERMINATION
Sec. 4201.401. REVIEW BY INDEPENDENT REVIEW ORGANIZATION;
COMPLIANCE WITH INDEPENDENT DETERMINATION. (a) A utilization
review agent shall allow any party whose appeal of an adverse
determination is denied by the agent to seek review of that
determination by an independent review organization assigned to
the appeal in accordance with Chapter 4202.
(b) The utilization review agent shall comply with the
independent review organization's determination regarding the
medical necessity or appropriateness of health care items and
services for an enrollee.
(c) The utilization review agent shall comply with the
independent review organization's determination regarding the
experimental or investigational nature of health care items and
services for an enrollee.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Amended by:
Acts 2009, 81st Leg., R.S., Ch.
1330, Sec. 11, eff. September 1, 2009.
Sec. 4201.402. INFORMATION PROVIDED TO INDEPENDENT REVIEW
ORGANIZATION. (a) Not later than the third business day after
the date a utilization review agent receives a request for
independent review, the agent shall provide to the appropriate
independent review organization:
(1) a copy of:
(A) any medical records of the enrollee that are relevant to the
review;
(B) any documents used by the plan in making the determination
to be reviewed;
(C) the written notification described by Section 4201.359; and
(D) any documents and other written information submitted to the
agent in support of the appeal; and
(2) a list of each physician or other health care provider who:
(A) has provided care to the enrollee; and
(B) may have medical records relevant to the appeal.
(b) A utilization review agent may provide confidential
information in the custody of the agent to an independent review
organization, subject to rules and standards adopted by the
commissioner under Chapter 4202.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4201.403. PAYMENT FOR INDEPENDENT REVIEW. A utilization
review agent shall pay for an independent review conducted under
this subchapter.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
SUBCHAPTER J. SPECIALTY UTILIZATION REVIEW AGENTS
Sec. 4201.451. DEFINITION. For purposes of this subchapter,
"specialty utilization review agent" means a utilization review
agent who conducts utilization review for a specialty health care
service, including dentistry, chiropractic services, or physical
therapy.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4201.452. INAPPLICABILITY OF CERTAIN OTHER LAW. A
specialty utilization review agent is not subject to Section
4201.151, 4201.152, 4201.206, 4201.252, or 4201.356.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4201.453. UTILIZATION REVIEW PLAN. A specialty utilization
review agent's utilization review plan, including reconsideration
and appeal requirements, must be reviewed by a health care
provider of the appropriate specialty and conducted in accordance
with standards developed with input from a health care provider
of the appropriate specialty.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4201.454. UTILIZATION REVIEW UNDER DIRECTION OF PROVIDER OF
SAME SPECIALTY. A specialty utilization review agent shall
conduct utilization review under the direction of a health care
provider who is of the same specialty as the agent and who is
licensed or otherwise authorized to provide the specialty health
care service by a state licensing agency in the United States.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4201.455. PERSONNEL. (a) Personnel who are employed by or
under contract with a specialty utilization review agent to
perform utilization review must be appropriately trained and
qualified.
(b) Personnel who obtain oral or written information directly
from a physician or other health care provider must be a nurse,
physician assistant, or other health care provider of the same
specialty as the agent and who are licensed or otherwise
authorized to provide the specialty health care service by a
state licensing agency in the United States.
(c) This section does not require personnel who perform only
clerical or administrative tasks to have the qualifications
prescribed by this section.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4201.456. OPPORTUNITY TO DISCUSS TREATMENT BEFORE ADVERSE
DETERMINATION. Subject to the notice requirements of Subchapter
G, before an adverse determination is issued by a specialty
utilization review agent who questions the medical necessity or
appropriateness, or the experimental or investigational nature,
of a health care service, the agent shall provide the health care
provider who ordered the service a reasonable opportunity to
discuss the patient's treatment plan and the clinical basis for
the agent's determination with a health care provider who is of
the same specialty as the agent.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Amended by:
Acts 2009, 81st Leg., R.S., Ch.
1330, Sec. 12, eff. September 1, 2009.
Sec. 4201.457. APPEAL DECISIONS. A specialty utilization review
agent shall comply with the requirement that a physician or other
health care provider who makes the decision in an appeal of an
adverse determination must be of the same or a similar specialty
as the health care provider who would typically manage the
specialty condition, procedure, or treatment under review in the
appeal.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
SUBCHAPTER L. CONFIDENTIALITY OF INFORMATION; ACCESS TO OTHER
INFORMATION
Sec. 4201.551. GENERAL CONFIDENTIALITY REQUIREMENT. (a) A
utilization review agent shall preserve the confidentiality of
individual medical records to the extent required by law.
(b) This chapter does not authorize a utilization review agent
to take any action that violates a state or federal law or
regulation concerning confidentiality of patient records.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4201.552. CONSENT REQUIREMENTS. (a) A utilization review
agent may not disclose individual medical records, personal
information, or other confidential information about a patient
obtained in the performance of utilization review without the
patient's prior written consent or except as otherwise required
by law.
(b) If the prior written consent is submitted by anyone other
than the patient who is the subject of the personal or
confidential information requested, the consent must:
(1) be dated; and
(2) contain the patient's signature.
(c) The patient's signature for purposes of Subsection (b)(2)
must have been obtained one year or less before the date the
disclosure is sought or the consent is invalid.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4201.553. PROVIDING INFORMATION TO AFFILIATED ENTITIES. A
utilization review agent may provide confidential information to
a third party under contract with or affiliated with the agent
solely to perform or assist with utilization review. Information
provided to a third party under this section remains
confidential.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4201.554. PROVIDING INFORMATION TO COMMISSIONER.
Notwithstanding this subchapter, a utilization review agent shall
provide to the commissioner on request individual medical records
or other confidential information to enable the commissioner to
determine compliance with this chapter. The information is
confidential and privileged and is not subject to Chapter 552,
Government Code, or to subpoena, except to the extent necessary
to enable the commissioner to enforce this chapter.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4201.555. ACCESS TO RECORDED PERSONAL INFORMATION. (a) If
an individual submits a written request to a utilization review
agent for access to recorded personal information concerning the
individual, the agent shall, within 10 business days from the
date the agent receives the request:
(1) inform the requesting individual in writing of the nature
and substance of the recorded personal information; and
(2) allow the individual, at the individual's discretion, to:
(A) view and copy, in person, the recorded personal information
concerning the individual; or
(B) obtain a copy of the information by mail.
(b) If the information requested under this section is in coded
form, the utilization review agent shall provide in writing an
accurate translation of the information in plain language.
(c) A utilization review agent's charges for providing a copy of
information requested under this section shall be reasonable, as
determined by rule adopted by the commissioner. The charges may
not include any costs otherwise recouped as part of the charges
for utilization review.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4201.556. PUBLISHING INFORMATION IDENTIFIABLE TO HEALTH
CARE PROVIDER. (a) A utilization review agent may not publish
data that identifies a particular physician or other health care
provider, including data in a quality review study or performance
tracking data, without providing prior written notice to the
physician or other provider.
(b) The prohibition under this section does not apply to
internal systems or reports used by the utilization review agent.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4201.557. REQUIREMENT TO MAINTAIN DATA IN CONFIDENTIAL
MANNER. A utilization review agent shall maintain all data
concerning a patient or physician or other health care provider
in a confidential manner that prevents unauthorized disclosure to
a third party.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4201.558. DESTRUCTION OF CERTAIN CONFIDENTIAL DOCUMENTS.
When a utilization review agent determines a document in the
custody of the agent that contains confidential patient
information or confidential physician or other health care
provider financial data is no longer needed, the document shall
be destroyed by a method that ensures the complete destruction of
the information.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
SUBCHAPTER M. ENFORCEMENT
Sec. 4201.601. NOTICE OF SUSPECTED VIOLATION; COMPELLING
PRODUCTION OF INFORMATION. If the commissioner believes that a
person or entity conducting utilization review is in violation of
this chapter or applicable rules, the commissioner:
(1) shall notify the utilization review agent, health
maintenance organization, or insurer of the alleged violation;
and
(2) may compel the production of documents or other information
as necessary to determine whether a violation has occurred.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4201.602. ENFORCEMENT PROCEEDING. (a) The commissioner
may initiate a proceeding under this subchapter.
(b) A proceeding under this chapter is a contested case for
purposes of Chapter 2001, Government Code.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4201.603. REMEDIES AND PENALTIES FOR VIOLATION. If the
commissioner determines that a utilization review agent, health
maintenance organization, insurer, or other person or entity
conducting utilization review has violated or is violating this
chapter, the commissioner may:
(1) impose a sanction under Chapter 82;
(2) issue a cease and desist order under Chapter 83; or
(3) assess an administrative penalty under Chapter 84.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.