4201.156
(a) A utilization review agent may not use an automated decision system to make, wholly or partly, an adverse determination. (b) The commissioner may audit and inspect at any time a utilization review agent’s use of an automated decision system for utilization review. (c) This section does not prohibit the use of an algorithm, artificial […]
4201.303
(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 and the source of the screening criteria and review procedures used as guidelines in making the adverse determination; and (4) a description of the procedure for the […]
4201.002
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 appropriate or are experimental or investigational (1-a) “Algorithm” means a computerized procedure consisting of a set of steps used to accomplish a determined […]
1305.004
(a) In this chapter, unless the context clearly indicates otherwise: (1) “Adverse determination” has the meaning assigned by Chapter 4201. (1-a) “Administrator” has the meaning assigned by Section 4151.001. (2) “Affiliate” means a person that directly, or indirectly through one or more intermediaries, controls or is controlled by, or is under common control with, the […]
1305.501
Repealed by Acts 2021, 87th Leg., Ch. 670 (H.B. 1753), § 3(1), eff. June 15, 2021 and Acts 2021, 87th Leg., Ch. 856 (S.B. 800), § 25(10), eff. Sept. 1, 2021 Added by Acts 2005, 79th Leg., ch. 265, § 4.02, eff. Sept. 1, 2005.
1305.502
(a) Not later than December 1 of each even-numbered year, the group shall develop and issue an informational report card that identifies and compares, on an objective basis, the quality, costs, health care provider availability, and other analogous factors of workers’ compensation health care networks operating under the workers’ compensation system of this state with […]
4201.656
(a) A physician or provider has a right to a review of an adverse determination regarding a preauthorization exemption be conducted by an independent review organization. A health maintenance organization or insurer may not require a physician or provider to engage in an internal appeal process before requesting a review by an independent review organization […]
4201.657
(a) A health maintenance organization or insurer is bound by an appeal or independent review determination that does not affirm the determination made by the health maintenance organization or insurer to rescind a preauthorization exemption. (b) A health maintenance organization or insurer may not retroactively deny a health care service on the basis of a […]
4201.658
After a final determination or review affirming the rescission or denial of an exemption for a specific health care service under Section 4201.653, a physician or provider is eligible for consideration of an exemption for the same health care service after the six-month evaluation period that follows the evaluation period which formed the basis of […]
4201.659
(a) A health maintenance organization or insurer may not deny or reduce payment to a physician or provider for a health care service for which the physician or provider has qualified for an exemption from preauthorization requirements under Section 4201.653 based on medical necessity or appropriateness of care unless the physician or provider: (1) knowingly […]