4201.454
A specialty utilization review agent shall conduct utilization review under the direction of a health care provider who is of the same specialty as the agent and who is licensed or otherwise authorized to provide the specialty health care service in this state. Added by Acts 2005, 79th Leg., ch. 727, § 4, eff. April […]
4201.455
(a) Personnel who are employed by or under contract with a specialty utilization review agent to perform utilization review must be appropriately trained and qualified and meet the requirements of this chapter and other applicable law of this state, including applicable licensing laws. (b) Personnel who obtain oral or written information directly from a physician […]
4201.356
(a) The procedures for appealing an adverse determination must provide that a physician licensed to practice medicine makes the decision on the appeal, except as provided by Subsection (b). (b) If not later than the 10th working day after the date an appeal is requested or denied the enrollee’s health care provider requests a particular […]
4201.357
(a) The procedures for appealing an adverse determination must include, in addition to the written appeal, a procedure for an expedited appeal of a denial of emergency care, a denial of continued hospitalization, or a denial of another service if the requesting health care provider includes a written statement with supporting documentation that the service […]
4201.251
A utilization review agent may delegate utilization review to qualified personnel in the hospital or other health care facility in which the health care services to be reviewed were or are to be provided. The delegation does not release the agent from the full responsibility for compliance with this chapter or other applicable law, including […]
4201.252
(a) Personnel employed by or under contract with a utilization review agent to perform utilization review must be appropriately trained and qualified and meet the requirements of this chapter and other applicable law, including applicable licensing requirements. (b) Personnel, other than a physician licensed to practice medicine, who obtain oral or written information directly from […]
4201.155
(a) A utilization review agent may not establish or impose a notice requirement or other review procedure that is contrary to the requirements of the health insurance policy or health benefit plan. (b) This section may not be construed to release a health insurance policy or health benefit plan from full compliance with this chapter […]
4201.151
A utilization review agent’s utilization review plan, including reconsideration and appeal requirements, must be reviewed by a physician licensed to practice medicine in this state and conducted in accordance with standards developed with input from appropriate health care providers and approved by a physician licensed to practice medicine in this state. Added by Acts 2005, […]
4201.152
A utilization review agent shall conduct utilization review under the direction of a physician licensed to practice medicine in this state. Added by Acts 2005, 79th Leg., ch. 727, § 4, eff. April 1, 2007. Amended by Acts 2019, 86th Leg., ch. 1218 (S.B. 1742), § 3.02, eff. Sept. 1, 2019.
1305.356
(a) A party to a medical dispute that remains unresolved after a review under Section 1305.355 is entitled to a contested case hearing. A hearing under this subsection shall be conducted by the department’s division of workers’ compensation in the same manner as a hearing conducted under Section 413.0311, Labor Code. (b) At a contested […]