All Things Texas Workers' Compensation

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Texas Insurance Code

Title 14. Utilization Review and Independent Review

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 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 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

§ 4201.156. Use of Automated Decision System for Adverse Determinations

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, Continued Hospitalization, Prescription Drugs or Intravenous Infusions
§ 4201.358. Response Letter to Interested Persons
§ 4201.359. Notice of Appeal
§ 4201.360. Immediate Appeal to Independent Review Organization in Life–Threatening Circumstances
§ 4201.3601. Immediate Appeal to Independent Review Organization for Denial of Prescription Drugs or Intravenous Infusions

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 K. Claims Review of Medical Necessity and Appropriateness

Repealed

§ 4202.501. Retrospective Review of Medical Necessity and Appropriateness
Repealed
§ 4202.502. Appeals of Retrospective Adverse Determinations
Repealed

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

Subchapter N. Exemption from Preauthorization Requirements for Physicians and Providers Providing Certain Health Care Services

§ 4201.651. Definitions
§ 4201.652. Applicability of Subchapter
§ 4201.653. Exemption from Preauthorization Requirements for Physicians and Providers Providing Certain Health Care Services
§ 4201.654. Duration of Preauthorization Exemption
§ 4201.655. Denial or Rescission of Preauthorization Exemption
§ 4201.656. Independent Review of Exemption Determination
§ 4201.657. Effect of Appeal or Independent Review Determination
§ 4201.658. Eligibility for Preauthorization Exemption Following Finalized Exemption Rescission or Denial
§ 4201.659. Effect of Preauthorization Exemption

Chapter 4203. Prohibited Consultant Activities

§ 4203.001. Definition
§ 4203.002. Prohibited Consultant Activities