4201.653
(a) A health maintenance organization or an insurer that uses a preauthorization process for health care services may not require a physician or provider to obtain preauthorization for a particular health care service if, in the most recent six-month evaluation period, as described by Subsection (b), the health maintenance organization or insurer has approved or […]
4201.654
(a) A physician’s or provider’s exemption from preauthorization requirements under Section 4201.653 remains in effect until: (1) the 30th day after the date the health maintenance organization or insurer notifies the physician or provider of the health maintenance organization’s or insurer’s determination to rescind the exemption under Section 4201.655, if the physician or provider does […]
4201.655
(a) A health maintenance organization or insurer may rescind an exemption from preauthorization requirements under Section 4201.653 only: (1) during January or June of each year; (2) if the health maintenance organization or insurer makes a determination, on the basis of a retrospective review of a random sample of not fewer than five and no […]
4201.651
(a) In this subchapter, “preauthorization” means a determination by a health maintenance organization, insurer, or person contracting with a health maintenance organization or insurer that health care services proposed to be provided to a patient are medically necessary and appropriate. (b) In this subchapter, terms defined by Section 843.002, including “health care services,” “physician,” and […]
4201.652
<Text of section effective until April 1, 2025. See, also, § 4201.652 effective April 1, 2025.> This subchapter applies only to: (1) a health benefit plan offered by a health maintenance organization operating under Chapter 843, except that this subchapter does not apply to: (A) the child health plan program under Chapter 62, Health and […]
4201.206
(a) Subject to Subsection (b) and the notice requirements of Subchapter G, before an adverse determination is issued by a utilization review agent who questions the medical necessity, the appropriateness, or the experimental or investigational nature of a health care service, the agent shall provide the health care provider who ordered, requested, provided, or is […]
1305.355
(a) The utilization review agent shall: (1) permit the employee or person acting on behalf of the employee and the employee’s requesting provider whose reconsideration of an adverse determination is denied to seek review of that determination within the period prescribed by Subsection (b) by an independent review organization assigned in accordance with Chapter 4202 […]
1305.351
(a) The requirements of Chapter 4201 apply to utilization review conducted in relation to claims in a workers’ compensation health care network. In the event of a conflict between Chapter 4201 and this chapter, this chapter controls. (b) Any screening criteria used for utilization review related to a workers’ compensation health care network must be […]
4201.456
Subject to the notice requirements of Subchapter G, before an adverse determination is issued by a specialty utilization review agent who questions the medical necessity, the appropriateness, or the experimental or investigational nature of a health care service, the agent shall provide the health care provider who ordered, requested, or is to provide the service […]
4201.453
A specialty utilization review agent’s utilization review plan, including reconsideration and appeal requirements, must be: (1) reviewed by a health care provider of the appropriate specialty who is licensed or otherwise authorized to provide the specialty health care service in this state; and (2) conducted in accordance with standards developed with input from a health […]