4202.011
Repealed by Acts 2017, 85th Leg., Ch. 553 (S.B. 526), § 7(b), eff. Sept. 1, 2017; Acts 2017, 85th Leg., Ch. 755 (S.B. 1731), § 16(b), eff. Sept. 1, 2017 Added by Acts 2013, 83rd Leg., ch. 1024 (H.B. 2645), § 5, eff. Sept. 1, 2013.
4202.003
The standards adopted under Section 4202.002 must require each independent review organization to make the organization’s determination: (1) for a life-threatening condition as defined by Section 4201.002, the provision of prescription drugs or intravenous infusions for which the patient is receiving benefits under the health insurance policy, or a review of a step therapy protocol […]
4201.054
(a) Except as provided by this section, this chapter applies to utilization review of a health care service provided to a person eligible for workers’ compensation medical benefits under Title 5, Labor Code. The commissioner of workers’ compensation shall regulate as provided by this chapter a person who performs utilization review of a medical benefit […]
4201.3601
Notwithstanding any other law, in a circumstance involving the provision of prescription drugs or intravenous infusions for which the patient is receiving benefits under the health insurance policy, the enrollee is: (1) entitled to an immediate appeal to an independent review organization as provided by Subchapter I; and (2) not required to comply with procedures […]
4201.304
(a) Subject to Subsection (b), a utilization review agent shall provide notice of an adverse determination required by this subchapter as follows: (1) with respect to a patient who is hospitalized at the time of the adverse determination, within one working day by either telephone or electronic transmission to the provider of record, followed by […]
4201.204
(a) A utilization review agent shall establish and maintain a complaint system that provides reasonable procedures for the resolution of oral or written complaints initiated by enrollees, patients, or health care providers concerning the utilization review. (b) The complaint procedure must include a requirement that the utilization review agent provide a written response to the […]
4201.053
<Text of section effective until April 1, 2025. See, also, § 4201.053 effective April 1, 2025.> (a) Except as provided by Section 4201.057, this chapter does not apply to: (1) the state Medicaid program; (2) the services program for children with special health care needs under Chapter 35, Health and Safety Code; (3) a program […]
1305.153
(a) The amount of reimbursement for services provided by a network provider is determined by the contract between the network and the provider or group of providers. (b) If an insurance carrier or network has preauthorized a health care service, the insurance carrier or network or the network’s agent or other representative may not deny […]
4202.014
The commissioner shall suspend enforcement of any provision of this chapter that the commissioner determines to be preempted by 42 U.S.C. Section 300gg-19. Added by Acts 2013, 83rd Leg., ch. 1024 (H.B. 2645), § 5, eff. Sept. 1, 2013.
4202.012
The commissioner by rule shall require referral by random assignment of adverse determinations under Subchapter I, Chapter 4201, to independent review organizations. On referral of a determination, the commissioner shall notify: (1) the utilization review agent; (2) the payor; (3) the independent review organization; (4) the patient, as defined by Section 4201.002, or the patient’s […]