4201.457
A specialty utilization review agent shall comply with the requirement that a physician or other health care provider who makes the decision in an appeal of an adverse determination must be of the same or a similar specialty as the health care provider who would typically manage the specialty condition, procedure, or treatment under review […]
4201.452
A specialty utilization review agent is not subject to Section 4201.151, 4201.152, 4201.206, 4201.252, or 4201.356. Added by Acts 2005, 79th Leg., ch. 727, § 4, eff. April 1, 2007.
4201.402
(a) Not later than the third business day after the date a utilization review agent receives a request for independent review, the agent shall provide to the appropriate independent review organization: (1) a copy of: (A) any medical records of the enrollee that are relevant to the review; (B) any documents used by the plan […]
4201.403
A utilization review agent shall pay for an independent review conducted under this subchapter. Added by Acts 2005, 79th Leg., ch. 727, § 4, eff. April 1, 2007.
4201.451
For purposes of this subchapter, “specialty utilization review agent” means a utilization review agent who conducts utilization review for a specialty health care service, including dentistry, chiropractic services, or physical therapy. Added by Acts 2005, 79th Leg., ch. 727, § 4, eff. April 1, 2007.
4201.359
(a) The procedures for appealing an adverse determination must require written notice to the appealing party of the determination of the appeal as soon as practicable, but not later than the 30th calendar day, after the date the utilization review agent receives the appeal. (b) If the appeal is denied, the notice must include a […]
4201.360
Notwithstanding any other law, in a circumstance involving an enrollee’s life-threatening condition, 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 for an internal review of the utilization review agent’s adverse determination. Added by Acts 2005, 79th […]
4201.358
The procedures for appealing an adverse determination must provide that, after the utilization review agent has sought review of the appeal, the agent shall issue a response letter explaining the resolution of the appeal to: (1) the patient or a person acting on the patient’s behalf; and (2) the patient’s physician or other health care […]
4201.353
The procedures for appealing an adverse determination must be reasonable. Added by Acts 2005, 79th Leg., ch. 727, § 4, eff. April 1, 2007.
4201.354
The procedures for appealing an adverse determination must provide that the adverse determination may be appealed orally or in writing by: (1) an enrollee; (2) a person acting on the enrollee’s behalf; or (3) the enrollee’s physician or other health care provider. Added by Acts 2005, 79th Leg., ch. 727, § 4, eff. April 1, […]