CHAPTER 4202. INDEPENDENT REVIEW ORGANIZATIONS
INSURANCE CODE
TITLE 14. UTILIZATION REVIEW AND INDEPENDENT REVIEW
CHAPTER 4202. INDEPENDENT REVIEW ORGANIZATIONS
Sec. 4202.001. DEFINITION. In this chapter, "payor" has the
meaning assigned by Section 4201.002.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4202.002. ADOPTION OF STANDARDS FOR INDEPENDENT REVIEW
ORGANIZATIONS. (a) The commissioner shall adopt standards and
rules for:
(1) the certification, selection, and operation of independent
review organizations to perform independent review described by
Subchapter I, Chapter 4201; and
(2) the suspension and revocation of the certification.
(b) The standards adopted under this section must ensure:
(1) the timely response of an independent review organization
selected under this chapter;
(2) the confidentiality of medical records transmitted to an
independent review organization for use in conducting an
independent review;
(3) the qualifications and independence of each physician or
other health care provider making a review determination for an
independent review organization;
(4) the fairness of the procedures used by an independent review
organization in making review determinations; and
(5) the timely notice to an enrollee of the results of an
independent review, including the clinical basis for the review
determination.
(c) In addition to the standards described by Subsection (b),
the commissioner shall adopt standards and rules that:
(1) prohibit:
(A) more than one independent review organization from operating
out of the same office or other facility;
(B) an individual or entity from owning more than one
independent review organization;
(C) an individual from owning stock in or serving on the board
of more than one independent review organization;
(D) an individual who has served on the board of an independent
review organization whose certification was revoked for cause
from serving on the board of another independent review
organization before the fifth anniversary of the date on which
the revocation occurred;
(E) an attorney who is, or has in the past served as, the
registered agent for an independent review organization from
representing the independent review organization in legal
proceedings; and
(F) an independent review organization from disclosing
confidential patient information, except to a provider who is
under contract to perform the review; and
(2) require:
(A) an independent review organization to be based and certified
in this state and to locate the organization's primary offices in
this state;
(B) an independent review organization to voluntarily surrender
the organization's certification while the organization is under
investigation or as part of an agreed order; and
(C) an independent review organization to apply for and receive
a new certification after the organization is sold to a new
owner.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Amended by:
Acts 2009, 81st Leg., R.S., Ch.
1332, Sec. 1, eff. September 1, 2009.
Sec. 4202.003. REQUIREMENTS REGARDING TIMELINESS OF
DETERMINATION. The standards adopted under Section 4202.002 must
require each independent review organization to make the
organization's determination:
(1) for a life-threatening condition as defined by Section
4201.002, not later than the earlier of:
(A) the fifth day after the date the organization receives the
information necessary to make the determination; or
(B) the eighth day after the date the organization receives the
request that the determination be made; and
(2) for a condition other than a life-threatening condition, not
later than the earlier of:
(A) the 15th day after the date the organization receives the
information necessary to make the determination; or
(B) the 20th day after the date the organization receives the
request that the determination be made.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4202.004. CERTIFICATION. To be certified as an independent
review organization under this chapter, an organization must
submit to the commissioner an application in the form required by
the commissioner. The application must include:
(1) for an applicant that is publicly held, the name of each
shareholder or owner of more than five percent of any of the
applicant's stock or options;
(2) the name of any holder of the applicant's bonds or notes
that exceed $100,000;
(3) the name and type of business of each corporation or other
organization that the applicant controls or is affiliated with
and the nature and extent of the control or affiliation;
(4) the name and a biographical sketch of each director,
officer, and executive of the applicant and of any entity listed
under Subdivision (3) and a description of any relationship the
named individual has with:
(A) a health benefit plan;
(B) a health maintenance organization;
(C) an insurer;
(D) a utilization review agent;
(E) a nonprofit health corporation;
(F) a payor;
(G) a health care provider; or
(H) a group representing any of the entities described by
Paragraphs (A) through (G);
(5) the percentage of the applicant's revenues that are
anticipated to be derived from independent reviews conducted
under Subchapter I, Chapter 4201;
(6) a description of the areas of expertise of the physicians or
other health care providers making review determinations for the
applicant; and
(7) the procedures to be used by the applicant in making
independent review determinations under Subchapter I, Chapter
4201.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4202.005. PERIODIC REPORTING OF INFORMATION; ANNUAL
DESIGNATION. (a) An independent review organization shall
annually submit the information required in an application for
certification under Section 4202.004. Anytime there is a
material change in the information the organization included in
the application, the organization shall submit updated
information to the commissioner.
(b) The commissioner shall designate annually each organization
that meets the standards for an independent review organization
adopted under Section 4202.002.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4202.006. PAYORS FEES. The commissioner shall charge
payors fees in accordance with this chapter as necessary to fund
the operations of independent review organizations.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4202.007. OVERSIGHT. The commissioner shall provide
ongoing oversight of the independent review organizations to
ensure continued compliance with this chapter and the standards
and rules adopted under this chapter.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4202.008. PROHIBITED OWNERSHIP OR CONTROL OF INDEPENDENT
REVIEW ORGANIZATION. An independent review organization may not
be a subsidiary of, or in any way owned or controlled by, a payor
or a trade or professional association of payors.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4202.009. CONFIDENTIAL INFORMATION. Information that
reveals the identity of a physician or other individual health
care provider who makes a review determination for an independent
review organization is confidential.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.
Sec. 4202.010. IMMUNITY FROM LIABILITY. (a) An independent
review organization conducting an independent review under
Subchapter I, Chapter 4201, is not liable for damages arising
from the review determination made by the organization.
(b) This section does not apply to an act or omission of the
independent review organization that is made in bad faith or that
involves gross negligence.
Added by Acts 2005, 79th Leg., Ch.
727, Sec. 4, eff. April 1, 2007.