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(D) an individual who has served on the board of an independent review organization whose certification was revoked for cause from serving on the board of another independent review organization before the fifth anniversary of the date on which the revocation occurred;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.