4201.355
(a) The procedures for appealing an adverse determination must provide that, within five working days from the date the utilization review agent receives the appeal, the agent shall send to the appealing party a letter acknowledging the date of receipt. (b) The letter must also include a list of: (1) the procedures required by this […]
4201.351
For purposes of this subchapter, a complaint filed concerning dissatisfaction or disagreement with an adverse determination constitutes an appeal of that adverse determination. Added by Acts 2005, 79th Leg., ch. 727, § 4, eff. April 1, 2007.
4201.352
A utilization review agent shall maintain and make available a written description of the procedures for appealing an adverse determination. Added by Acts 2005, 79th Leg., ch. 727, § 4, eff. April 1, 2007.
4201.253
A utilization review agent may not permit or provide compensation or another thing of value to an employee or agent of the utilization review agent, condition employment of the agent’s employees or agent evaluations, or set employee or agent performance standards, based on the amount of volume of adverse determinations, reductions of or limitations on […]
4201.301
A utilization review agent shall provide notice of a determination made in a utilization review to: (1) the enrollee’s provider of record; and (2) the enrollee or a person acting on the enrollee’s behalf. Added by Acts 2005, 79th Leg., ch. 727, § 4, eff. April 1, 2007.
4201.302
A utilization review agent must mail or otherwise transmit the notice required by this subchapter not later than the second working day after the date of the request for utilization review and the agent receives all information necessary to complete the review. Added by Acts 2005, 79th Leg., ch. 727, § 4, eff. April 1, […]
4201.203
(a) A utilization review agent may not require, as a condition of treatment approval or for any other reason, the observation of a psychotherapy session or the submission or review of a mental health therapist’s process or progress notes. (b) Notwithstanding this section, a utilization review agent may require submission of a patient’s medical record […]
4201.205
(a) A health care provider may designate one or more individuals as the initial contact or contacts for a utilization review agent seeking routine information or data. (b) A designation made under this section may not preclude a utilization review agent or medical advisor from contacting a health care provider or the provider’s employees who […]
4201.154
(a) A utilization review agent’s written screening criteria and review procedures shall be made available for: (1) review and inspection to determine appropriateness and compliance as considered necessary by the commissioner; and (2) copying as necessary for the commissioner to accomplish the commissioner’s duties under this code. (b) Any information obtained or acquired under the […]
4201.201
A utilization review agent: (1) may not engage in unnecessary or unreasonable repetitive contacts with a health care provider or patient; and (2) shall base the frequency of contacts or reviews on the severity or complexity of the patient’s condition or on necessary treatment and discharge planning activity. Added by Acts 2005, 79th Leg., ch. […]