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Texas Statutes (Last Updated: January 4, 2014) |
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INSURANCE CODE |
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Title 14. UTILIZATION REVIEW AND INDEPENDENT REVIEW |
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Chapter 4201. UTILIZATION REVIEW AGENTS |
| Subchapter A. GENERAL PROVISIONS |
| § 4201.001. PURPOSE |
| § 4201.002. DEFINITIONS |
| § 4201.003. RULES |
| § 4201.004. TELEPHONE ACCESS |
| Subchapter B. APPLICABILITY OF CHAPTER |
| § 4201.051. PERSONS PROVIDING INFORMATION ABOUT SCOPE OF COVERAGE OR BENEFITS |
| § 4201.052. CERTAIN CONTRACTS WITH FEDERAL GOVERNMENT |
| § 4201.053. MEDICAID AND CERTAIN OTHER STATE HEALTH OR MENTAL HEALTH PROGRAMS |
| § 4201.054. WORKERS' COMPENSATION BENEFITS |
| § 4201.055. HEALTH CARE SERVICE PROVIDED UNDER AUTOMOBILE INSURANCE POLICY |
| § 4201.056. EMPLOYEE WELFARE BENEFIT PLANS |
| § 4201.057. HEALTH MAINTENANCE ORGANIZATIONS |
| § 4201.058. INSURERS |
| Subchapter C. CERTIFICATION |
| § 4201.101. CERTIFICATE OF REGISTRATION REQUIRED |
| § 4201.102. REQUIREMENTS FOR CERTIFICATION |
| § 4201.103. CERTIFICATE RENEWAL |
| § 4201.104. CERTIFICATION AND RENEWAL FORMS |
| § 4201.105. FEES |
| § 4201.106. CERTIFICATE NOT TRANSFERABLE |
| § 4201.107. REPORTING MATERIAL CHANGES |
| § 4201.108. LIST OF UTILIZATION REVIEW AGENTS |
| Subchapter D. UTILIZATION REVIEW: GENERAL STANDARDS |
| § 4201.151. UTILIZATION REVIEW PLAN |
| § 4201.152. UTILIZATION REVIEW UNDER DIRECTION OF PHYSICIAN |
| § 4201.153. SCREENING CRITERIA AND REVIEW PROCEDURES |
| § 4201.154. REVIEW AND INSPECTION OF SCREENING CRITERIA AND REVIEW PROCEDURES |
| § 4201.155. LIMITATION ON NOTICE REQUIREMENTS AND REVIEW PROCEDURES |
| Subchapter E. UTILIZATION REVIEW: RELATIONS WITH PATIENTS AND HEALTH CARE PROVIDERS |
| § 4201.201. REPETITIVE CONTACTS WITH HEALTH CARE PROVIDER OR PATIENT; FREQUENCY OF REVIEWS |
| § 4201.202. OBSERVING OR PARTICIPATING IN PATIENT'S CARE |
| § 4201.203. MENTAL HEALTH THERAPY |
| § 4201.204. COMPLAINT SYSTEM |
| § 4201.205. DESIGNATED INITIAL CONTACT |
| § 4201.206. OPPORTUNITY TO DISCUSS TREATMENT BEFORE ADVERSE DETERMINATION |
| § 4201.207. CHARGES BY HEALTH CARE PROVIDER FOR PROVIDING MEDICAL INFORMATION |
| Subchapter F. UTILIZATION REVIEW: PERSONNEL |
| § 4201.251. DELEGATION OF UTILIZATION REVIEW |
| § 4201.252. PERSONNEL |
| § 4201.253. PROHIBITED BASES FOR EMPLOYMENT, COMPENSATION, EVALUATIONS, OR PERFORMANCE STANDARDS |
| Subchapter G. NOTICE OF DETERMINATIONS |
| § 4201.301. GENERAL DUTY TO NOTIFY |
| § 4201.302. GENERAL TIME FOR NOTICE |
| § 4201.303. ADVERSE DETERMINATION: CONTENTS OF NOTICE |
| § 4201.304. TIME FOR NOTICE OF ADVERSE DETERMINATION |
| § 4201.305. NOTICE OF ADVERSE DETERMINATION FOR RETROSPECTIVE UTILIZATION REVIEW |
| Subchapter H. APPEAL OF ADVERSE DETERMINATION |
| § 4201.351. COMPLAINT AS APPEAL |
| § 4201.352. WRITTEN DESCRIPTION OF APPEAL PROCEDURES |
| § 4201.353. APPEAL PROCEDURES MUST BE REASONABLE |
| § 4201.354. PERSONS OR ENTITIES WHO MAY APPEAL |
| § 4201.355. ACKNOWLEDGMENT OF APPEAL |
| § 4201.356. DECISION BY PHYSICIAN REQUIRED; SPECIALTY REVIEW |
| § 4201.357. EXPEDITED APPEAL FOR DENIAL OF EMERGENCY CARE OR CONTINUED HOSPITALIZATION |
| § 4201.358. RESPONSE LETTER TO INTERESTED PERSONS |
| § 4201.359. NOTICE OF APPEAL |
| § 4201.360. IMMEDIATE APPEAL TO INDEPENDENT REVIEW ORGANIZATION IN LIFE-THREATENING CIRCUMSTANCES |
| Subchapter I. INDEPENDENT REVIEW OF ADVERSE DETERMINATION |
| § 4201.401. REVIEW BY INDEPENDENT REVIEW ORGANIZATION; COMPLIANCE WITH INDEPENDENT DETERMINATION |
| § 4201.402. INFORMATION PROVIDED TO INDEPENDENT REVIEW ORGANIZATION |
| § 4201.403. PAYMENT FOR INDEPENDENT REVIEW |
| Subchapter J. SPECIALTY UTILIZATION REVIEW AGENTS |
| § 4201.451. DEFINITION |
| § 4201.452. INAPPLICABILITY OF CERTAIN OTHER LAW |
| § 4201.453. UTILIZATION REVIEW PLAN |
| § 4201.454. UTILIZATION REVIEW UNDER DIRECTION OF PROVIDER OF SAME SPECIALTY |
| § 4201.455. PERSONNEL |
| § 4201.456. OPPORTUNITY TO DISCUSS TREATMENT BEFORE ADVERSE DETERMINATION |
| § 4201.457. APPEAL DECISIONS |
| Subchapter L. CONFIDENTIALITY OF INFORMATION; ACCESS TO OTHER INFORMATION |
| § 4201.551. GENERAL CONFIDENTIALITY REQUIREMENT |
| § 4201.552. CONSENT REQUIREMENTS |
| § 4201.553. PROVIDING INFORMATION TO AFFILIATED ENTITIES |
| § 4201.554. PROVIDING INFORMATION TO COMMISSIONER |
| § 4201.555. ACCESS TO RECORDED PERSONAL INFORMATION |
| § 4201.556. PUBLISHING INFORMATION IDENTIFIABLE TO HEALTH CARE PROVIDER |
| § 4201.557. REQUIREMENT TO MAINTAIN DATA IN CONFIDENTIAL MANNER |
| § 4201.558. DESTRUCTION OF CERTAIN CONFIDENTIAL DOCUMENTS |
| Subchapter M. ENFORCEMENT |
| § 4201.601. NOTICE OF SUSPECTED VIOLATION; COMPELLING PRODUCTION OF INFORMATION |
| § 4201.602. ENFORCEMENT PROCEEDING |
| § 4201.603. REMEDIES AND PENALTIES FOR VIOLATION |