TLC: Insurance Code Proposed Chapters

79C42(3) KLA

CHAPTER 4201. UTILIZATION REVIEW AGENTS

SUBCHAPTER A. GENERAL PROVISIONS

Revised Law

Sec. 4201.001. PURPOSE. The purpose of this chapter is to:

(1) promote the delivery of quality health care in a cost-effective manner;

(2) ensure that a utilization review agent adheres to reasonable standards for conducting utilization review;

(3) foster greater coordination and cooperation between a health care provider and utilization review agent;

(4) improve communications and knowledge of benefits among all parties concerned before an expense is incurred; and

(5) ensure that a utilization review agent maintains the confidentiality of medical records in accordance with applicable law. (V.T.I.C. Art. 21.58A, Sec. 1.)

Source Law

Art. 21.58A

Sec. 1. The purpose of this article is to:

(1) promote the delivery of quality health care in a cost-effective manner;

(2) assure that utilization review agents adhere to reasonable standards for conducting utilization reviews;

(3) foster greater coordination and cooperation between health care providers and utilization review agents;

(4) improve communications and knowledge of benefits among all parties concerned before expenses are incurred; and

(5) ensure that utilization review agents maintain the confidentiality of medical records in accordance with applicable law.

Revised Law

Sec. 4201.002. DEFINITIONS. In this chapter:

(1) "Adverse determination" means a determination by a utilization review agent that health care services provided or proposed to be provided to a patient are not medically necessary.

(2) "Emergency care" means health care services provided in a hospital emergency facility or comparable facility to evaluate and stabilize medical conditions of a recent onset and severity, including severe pain, that would lead a prudent layperson possessing an average knowledge of medicine and health to believe that the individual's condition, sickness, or injury is of such a nature that failure to get immediate medical care could:

(A) place the individual's health in serious jeopardy;

(B) result in serious impairment to bodily functions;

(D) result in serious disfigurement; or

(E) for a pregnant woman, result in serious jeopardy to the health of the fetus.

(3) "Enrollee" means an individual covered by a health insurance policy or health benefit plan. The term includes an individual who is covered as an eligible dependent of another individual.

(4) "Health benefit plan" means a plan of benefits, other than a health insurance policy, that:

(A) defines the coverage provisions for health care for enrollees; and

(B) is offered or provided by a public or private organization.

(5) "Health care provider" means a person, corporation, facility, or institution that is:

(A) licensed by a state to provide or is otherwise lawfully providing health care services; and

(B) eligible for independent reimbursement for those health care services.

(6) "Health insurance policy" means an insurance policy, including a policy written by a corporation subject to Chapter 842, that provides coverage for medical or surgical expenses incurred as a result of accident or sickness.

(7) "Life-threatening" means a disease or condition from which the likelihood of death is probable unless the course of the disease or condition is interrupted.

(8) "Nurse" means a professional or registered nurse, a licensed vocational nurse, or a licensed practical nurse.

(9) "Patient" means the enrollee or an eligible dependent of the enrollee under a health benefit plan or health insurance policy.

(10) "Payor" means:

(A) an insurer that writes health insurance policies;

(B) a preferred provider organization, health maintenance organization, or self-insurance plan; or

(C) any other person or entity that provides, offers to provide, or administers hospital, outpatient, medical, or other health benefits to a person treated by a health care provider in this state under a policy, plan, or contract.

(11) "Physician" means a licensed doctor of medicine or a doctor of osteopathy.

(12) "Provider of record" means the physician or other health care provider with primary responsibility for the care, treatment, and services provided to an enrollee. The term includes a health care facility if treatment is provided on an inpatient or outpatient basis.

(13) "Utilization review" means a system for prospective or concurrent review of the medical necessity and appropriateness of health care services being provided or proposed to be provided to an individual in this state. The term does not include a review in response to an elective request for clarification of coverage.

(14) "Utilization review agent" means an entity that conducts utilization review for:

(A) an employer with employees in this state who are covered under a health benefit plan or health insurance policy;

(B) a payor; or

(15) "Utilization review plan" means the screening criteria and utilization review procedures of a utilization review agent.

(16) "Working day" means a weekday that is not a legal holiday. (V.T.I.C. Art. 21.58A, Sec. 2 (part).)

Source Law

Sec. 2. In this article:

…

(2) "Administrator" means a person holding a certificate of authority under Article 21.07-6 of this code.

(3) "Adverse determination" means a determination by a utilization review agent that the health care services furnished or proposed to be furnished to a patient are not medically necessary.

…

(6) "Emergency care" means health care services provided in a hospital emergency facility or comparable facility to evaluate and stabilize medical conditions of a recent onset and severity, including but not limited to severe pain, that would lead a prudent layperson possessing an average knowledge of medicine and health to believe that his or her condition, sickness, or injury is of such a nature that failure to get immediate medical care could result in:

(A) placing the patient's health in serious jeopardy;

(B) serious impairment to bodily functions;

(D) serious disfigurement; or

(E) in the case of a pregnant woman, serious jeopardy to the health of the fetus.

…

(8) "Enrollee" means a person covered by a health insurance policy or plan and includes a person who is covered as an eligible dependent of another person.

(9) "Health benefit plan" means a plan of benefits that defines the coverage provisions for health care for enrollees offered or provided by any organization, public or private, other than health insurance.

(10) "Health care provider" means any person, corporation, facility, or institution licensed by a state to provide or otherwise lawfully providing health care services that is eligible for independent reimbursement for those services.

(11) "Health insurance policy" means an insurance policy, including a policy written by a company subject to Chapter 20 of this code, that provides coverage for medical or surgical expenses incurred as a result of accident or sickness.

(12) "Life threatening" means a disease or condition for which the likelihood of death is probable unless the course of the disease or condition is interrupted.

(13) "Nurse" means a professional or registered nurse, a licensed vocational nurse, or a licensed practical nurse.

…

(16) "Patient" means the enrollee or an eligible dependent of the enrollee under a health benefit plan or health insurance plan.

(17) "Payor" means:

(A) an insurer writing health insurance policies;

(B) any preferred provider organization, health maintenance organization, self-insurance plan; or

(C) any other person or entity which provides, offers to provide, or administers hospital, outpatient, medical, or other health benefits to persons treated by a health care provider in this state pursuant to any policy, plan, or contract.

(18) "Physician" means a licensed doctor of medicine or a doctor of osteopathy.

(19) "Provider of record" means the physician or other health care provider that has primary responsibility for the care, treatment, and services rendered to the enrollee and includes any health care facility when treatment is rendered on an inpatient or outpatient basis.

(20) "Utilization review" means a system for prospective or concurrent review of the medical necessity and appropriateness of health care services being provided or proposed to be provided to an individual within this state. Utilization review shall not include elective requests for clarification of coverage.

(21) "Utilization review agent" means an entity that conducts utilization review for:

(A) an employer with employees in this state who are covered under a health benefit plan or health insurance policy;

(B) a payor; or

(22) "Utilization review plan" means the screening criteria and utilization review procedures of a utilization review agent.

(23) "Working day" means a weekday, excluding a legal holiday.

Revisor's Note

(1) Section 2(1), V.T.I.C. Article 21.58A, defines "administrative procedure act." The revised law omits the definition as unnecessary and substitutes a reference to Chapter 2001, Government Code, which is the Administrative Procedure Act, for references to the "administrative procedure act" throughout this chapter. The omitted law reads:

(1) "Administrative procedure act" means Chapter 2001, Government Code.

(2) Section 2(2), V.T.I.C. Article 21.58A, defines "administrator." The revised law incorporates the substance of the definition of "administrator" into the definition of "utilization review agent" provided by Section 2(21), V.T.I.C. Article 21.58A, revised in this chapter as Section 4201.002(14), because that is the only other use of the term "administrator" in V.T.I.C. Article 21.58A, revised as this chapter. In addition, the definition of "administrator" in Section 2(2) includes a reference to "a certificate of authority under Article 21.07-6." V.T.I.C. Article 21.07-6 is revised in various chapters in this code. The relevant provisions are revised in Chapter 4151 of this code, and the revised law is drafted accordingly.

(3) Section 2(4), V.T.I.C. Article 21.58A, in part defines "certificate" for purposes of Article 21.58A to mean a certificate of registration. The revised law omits the provision as unnecessary and substitutes a reference to a "certificate of registration" for references to a "certificate" throughout this chapter. The omitted law reads:

(4) "Certificate" means a certificate of registration … .

(4) Section 2(5), V.T.I.C. Article 21.58A, defines "commissioner" to mean the commissioner of insurance. The revised law omits the definition as unnecessary because Section 31.001 of this code defines "commissioner" for purposes of this code and the other insurance laws of this state to mean the commissioner of insurance. The omitted law reads:

(5) "Commissioner" means the commissioner of insurance.

(5) Section 2(6), V.T.I.C. Article 21.58A, refers to "including but not limited to." "[B]ut not limited to" is omitted as unnecessary because Section 311.005(13), Government Code (Code Construction Act), applicable to the revised law, and Section 312.011(19), Government Code, provide that "includes" and "including" are terms of enlargement and not of limitation and do not create a presumption that components not expressed are excluded.

(6) Section 2(7), V.T.I.C. Article 21.58A, defines the term "dental plan." The revised law omits the term as unnecessary because V.T.I.C. Article 21.58A does not use the defined term. The omitted law reads:

(7) "Dental plan" means an insurance policy or health benefit plan, including a policy written by a company subject to Chapter 20 of this code, that provides coverage for expenses for dental services.

(7) Section 2(8), V.T.I.C. Article 21.58A, defines the term "enrollee" in part by referring to an individual covered by a health insurance policy or "plan." The revised law substitutes a reference to "health benefit plan" for "plan" because "health benefit plan" is the defined term under Section 2(9), V.T.I.C. Article 21.58A, revised in this chapter as Section 4201.002(4).

(8) Section 2(9), V.T.I.C. Article 21.58A, refers to a health benefit plan other than "health insurance," and Section 2(16), V.T.I.C. Article 21.58A, defines the term "patient" in part by referring to "a health benefit plan or health insurance plan." The revised law substitutes a reference to a "health insurance policy" for the references to "health insurance" and "health insurance plan" because "health insurance policy," rather than "health insurance" or "health insurance plan," is the defined term under Section 2(11), V.T.I.C. Article 21.58A, revised in this chapter as Section 4201.002(6).

(9) Section 2(14), V.T.I.C. Article 21.58A, defines "open meetings law" to mean Chapter 551, Government Code. The revised law omits the definition as unnecessary and substitutes a reference to Chapter 551, Government Code, which is the open meetings law, for references to the "open meetings law" throughout this chapter. The omitted law reads:

(14) "Open meetings law" means Chapter 551, Government Code.

(10) Section 2(15), V.T.I.C. Article 21.58A, defines "open records law" to mean Chapter 552, Government Code. Chapter 1035, Acts of the 74th Legislature, Regular Session, 1995, changed the heading of Chapter 552, Government Code, from "Open Records" to "Public Information." The revised law omits the definition as unnecessary and substitutes a reference to Chapter 552, Government Code, which is the public information law, for references to the "open records law" throughout this chapter. The omitted law reads:

(15) "Open records law" means Chapter 552, Government Code.

Revised Law

Sec. 4201.003. RULES. (a) The commissioner may adopt rules to implement this chapter.

(b) A rule adopted under this chapter relates only to a person or entity subject to this chapter.

(c) The commissioner shall appoint an advisory committee to advise the commissioner on development of rules regarding the administration of this chapter, as authorized by Section 2001.031, Government Code. The committee includes:

(1) the public counsel appointed under Chapter 501; and

(2) one representative for each of the following:

(A) insurers;

(B) health maintenance organizations;

(D) utilization review agents;

(E) employers;

(F) consumer organizations;

(G) physicians;

(H) dentists;

(I) hospitals;

(J) registered nurses; and

(K) other health care providers.

(d) The advisory committee's deliberations are subject to Chapter 551, Government Code. (V.T.I.C. Art. 21.58A, Secs. 13, 14(f).)

Source Law

Sec. 13. The commissioner may have the authority to adopt rules and regulations to implement the provisions of this article. The commissioner shall appoint an advisory committee to advise the commissioner in developing rules and regulations to administer this article as authorized by Section 2001.031, Government Code. The committee's deliberations shall be subject to the open meetings law. The committee shall include the public counsel and one representative for each of the following: insurance companies, health maintenance organizations, group hospital service corporations, utilization review agents, employers, consumer organizations, physicians, dentists, hospitals, registered nurses, and other health care providers.

[Sec. 14]

(f) Any regulations promulgated pursuant to this article shall relate only to persons or entities subject to this article.

Revisor's Note

(1) Section 13, V.T.I.C. Article 21.58A, refers to "rules and regulations." Throughout this chapter, the reference to "regulations" is omitted from the revised law because under Section 311.005(5), Government Code (Code Construction Act), applicable to the revised law, a rule is defined to include a regulation.

(2) Section 13, V.T.I.C. Article 21.58A, refers to "the public counsel." For the convenience of the reader, the revised law adds "appointed under Chapter 501" when referring to the public counsel because the public counsel is appointed under that chapter to serve as the executive director of the office of public insurance counsel.

(3) Section 14(f), V.T.I.C. Article 21.58A, refers to "regulations" adopted under Article 21.58A. The revised law substitutes "rules" for "regulations" because, in this context, the terms are synonymous and because of the reason stated in Revisor's Note (1) to this section.

Revised Law

Sec. 4201.004. TELEPHONE ACCESS. (a) A utilization review agent shall:

(1) have appropriate personnel reasonably available, by toll-free telephone at least 40 hours per week during normal business hours in this state, to discuss patients' care and allow response to telephone review requests;

(2) have a telephone system capable, during hours other than normal business hours, of accepting or recording incoming telephone calls or of providing instructions to a caller; and

(3) respond to a call made during hours other than normal business hours not later than the second working day after the later of:

(A) the date the call was received; or

(B) the date the details necessary to respond have been received from the caller.

(b) A utilization review agent must provide to the commissioner a written description of the procedures to be used when responding with respect to poststabilization care subsequent to emergency treatment as requested by a treating physician or other health care provider. (V.T.I.C. Art. 21.58A, Sec. 7.)

Source Law

Sec. 7. (a) A utilization review agent shall have appropriate personnel reasonably available by toll-free telephone at least 40 hours per week during normal business hours in Texas to discuss patients' care and allow response to telephone review requests.

(b) A utilization review agent must have a telephone system capable of accepting or recording or providing instructions to incoming phone calls during other than normal business hours and shall respond to such calls not later than two working days of the later of the date on which the call was received or the date the details necessary to respond have been received from the caller.

(c) A utilization review agent must provide a written description to the commissioner setting forth the procedures to be used when responding to poststabilization care subsequent to emergency treatment as requested by a treating physician or health care provider.

[Sections 4201.005-4201.050 reserved for expansion]

SUBCHAPTER B. APPLICABILITY OF CHAPTER

Revised Law

Sec. 4201.051. PERSONS PROVIDING INFORMATION ABOUT SCOPE OF COVERAGE OR BENEFITS. This chapter does not apply to a person who:

(1) provides information to an enrollee about scope of coverage or benefits provided under a health insurance policy or health benefit plan; and

(2) does not determine whether a particular health care service provided or to be provided to an enrollee is medically necessary or appropriate. (V.T.I.C. Art. 21.58A, Sec. 14(a).)

Source Law

Sec. 14. (a) This article shall not apply to a person who provides information to enrollees about scope of coverage or benefits provided under a health insurance policy or health benefit plan and who does not determine whether particular health care services provided or to be provided to an enrollee are medically necessary or appropriate.

Revised Law

Sec. 4201.052. CERTAIN CONTRACTS WITH FEDERAL GOVERNMENT. This chapter does not apply to a contract with the federal government to provide utilization review with respect to a patient who is eligible for services under Title XVIII or XIX of the Social Security Act (42 U.S.C. Section 1395 et seq. or Section 1396 et seq.). (V.T.I.C. Art. 21.58A, Sec. 14(b)(1).)

Source Law

(b)(1) This article shall not apply to any contract with the federal government for utilization review of patients eligible for services under Title XVIII or XIX of the Social Security Act (42 U.S.C. Section 1395 et seq. or Section 1396 et seq.).

Revised Law

Sec. 4201.053. MEDICAID AND CERTAIN OTHER STATE HEALTH OR MENTAL HEALTH PROGRAMS. 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 administered under Title 2, Human Resources Code;

(4) a program of the Department of State Health Services relating to mental health services;

(5) a program of the Department of Aging and Disability Services relating to mental retardation services; or

(6) a program of the Texas Department of Criminal Justice. (V.T.I.C. Art. 21.58A, Sec. 14(b)(2).)

Source Law

(2) Except as provided by Subsection (g) of this section, this article shall not apply to the Texas Medicaid Program, the services program for children with special health care needs created pursuant to Chapter 35, Health and Safety Code, any program administered under Title 2, Human Resources Code, any program of the Texas Department of Mental Health and Mental Retardation, or any program of the Texas Department of Criminal Justice.

Revisor's Note

Section 14(b)(2), V.T.I.C. Article 21.58A, refers to a program of the Texas Department of Mental Health and Mental Retardation. In Chapter 198, Acts of the 78th Legislature, Regular Session, 2003, the legislature directed the consolidation of health and human services agencies and programs. Under the authority of Section 1.26 of that act, the Texas Department of Mental Health and Mental Retardation was abolished. The programs and functions of that department were transferred under Sections 1.19 and 1.20 of the act to the Department of State Health Services and the Department of Aging and Disability Services, respectively. The revised law is drafted accordingly.

Revised Law

Sec. 4201.054. WORKERS' COMPENSATION BENEFITS. (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 shall regulate as provided by this chapter a person who performs utilization review of a medical benefit provided under Chapter 408, Labor Code.

(b) This section does not affect the authority of the Texas Workers' Compensation Commission to exercise the powers granted to that commission under Title 5, Labor Code.

(d) The commissioner and the Texas Workers' Compensation Commission may adopt rules and enter into memoranda of understanding as necessary to implement this section. (V.T.I.C. Art. 21.58A, Sec. 14(c).)

Source Law

(c) Except as otherwise provided by this subsection, this article applies to utilization review of health care services provided to persons eligible for workers' compensation medical benefits under Title 5, Labor Code. The commissioner shall regulate in the manner provided by this article a person who performs review of a medical benefit provided under Chapter 408, Labor Code. This subsection does not affect the authority of the Texas Workers' Compensation Commission to exercise the powers granted to that commission under Title 5, Labor Code. In the event of a conflict between this article and Title 5, Labor Code, Title 5, Labor Code, prevails. The commissioner and the Texas Workers' Compensation Commission may adopt rules and enter into memoranda of understanding as necessary to implement this subsection.

Revised Law

Sec. 4201.055. HEALTH CARE SERVICE PROVIDED UNDER AUTOMOBILE INSURANCE POLICY. This chapter does not apply to utilization review of a health care service provided under an automobile insurance policy or contract that is authorized under Chapter 2301 or Article 5.13-2 or that is issued under Chapter 981. (V.T.I.C. Art. 21.58A, Sec. 14(d).)

Source Law

(d) This article shall not apply to utilization review of health care services provided under a policy or contract of automobile insurance promulgated by the board under Subchapter A, Chapter 5 of this code or issued pursuant to Article 1.14-2 of this code.

Revisor's Note

(1) Section 14(d), V.T.I.C. Article 21.58A, refers to "a policy or contract of automobile insurance promulgated by the board," meaning the State Board of Insurance, "under Subchapter A, Chapter 5 of this code." Chapter 685, Acts of the 73rd Legislature, Regular Session, 1993, abolished the board and transferred its functions to the commissioner of insurance and the Texas Department of Insurance. Throughout this chapter, references to the board have been changed appropriately.

Before the regular session of the 78th Legislature, the commissioner adopted policy forms and endorsements for automobile insurance under V.T.I.C. Article 5.06. Chapter 206, Acts of the 78th Legislature, Regular Session, 2003, amended Article 5.06 to provide that, effective June 11, 2003, forms for automobile insurance are regulated under V.T.I.C. Article 5.13-2, which is revised in part as Subchapter A, Chapter 2301. That act also amended Article 5.06 and V.T.I.C. Article 5.145, revised in relevant part as Subchapter B, Chapter 2301, to authorize insurers to continue to use policy forms and endorsements for personal automobile insurance promulgated, approved, or adopted by the commissioner under Article 5.06 before June 11, 2003, on notification to the commissioner. For that reason, the revised law substitutes a reference to "an automobile insurance policy or contract that is authorized under Chapter 2301 or Article 5.13-2" for the reference to "a policy or contract of automobile insurance promulgated … under Subchapter A, Chapter 5."

(2) Section 14(d), V.T.I.C. Article 21.58A, refers to an automobile insurance policy or contract "issued pursuant to Article 1.14-2 of this code." V.T.I.C. Article 1.14–2 was revised in various chapters in this code. The relevant provisions are revised in Chapter 981 of this code, and the revised law is drafted accordingly.

Revised Law

Sec. 4201.056. EMPLOYEE WELFARE BENEFIT PLANS. This chapter does not apply to the terms or benefits of an employee welfare benefit plan defined by Section 3(1) of the Employee Retirement Income Security Act of 1974 (29 U.S.C. Section 1002(1)). (V.T.I.C. Art. 21.58A, Sec. 14(e).)

Source Law

(e) This article shall not apply to the terms or benefits of employee welfare benefit plans as defined in Section 3(1) of the Employee Retirement Income Security Act of 1974 (29 U.S.C. Section 1002(1)).

Revised Law

Sec. 4201.057. HEALTH MAINTENANCE ORGANIZATIONS. (a) In this section, "health maintenance organization" includes a health maintenance organization that contracts with the Health and Human Services Commission or with an agency operating part of the state Medicaid managed care program to provide health care services to recipients of medical assistance under Chapter 32, Human Resources Code.

(b) This chapter applies to a health maintenance organization except as expressly provided by this section.

(c) As a condition of holding a certificate of authority to engage in the business of a health maintenance organization, a health maintenance organization that performs utilization review must:

(1) comply with this chapter, except Subchapter C; and

(2) submit to assessment of a maintenance tax under Chapter 258 to cover the costs of administering compliance with this subsection.

(d) The commissioner shall adopt rules for appropriate verification and enforcement of compliance with Subsection (c).

(e) Notwithstanding Subsection (c)(1), a health maintenance organization that performs utilization review for a person or entity subject to this chapter, other than a person or entity for which the health maintenance organization is the payor, must obtain a certificate of registration under Subchapter C and shall comply with all of the provisions of this chapter.

(f) This chapter does not prohibit or limit the distribution of a portion of the savings from the reduction or elimination of unnecessary medical services, treatment, supplies, confinements, or days of confinement in a health care facility through profit sharing, bonus, or withholding arrangements to a participating physician or participating health care provider for providing health care services to an enrollee. (V.T.I.C. Art. 21.58A, Secs. 14(g), (i) (part).)

Source Law

(g) A health maintenance organization, including a health maintenance organization that contracts with the Health and Human Services Commission or an agency operating part of the state Medicaid managed care program to provide health care services to recipients of medical assistance under Chapter 32, Human Resources Code, is subject to this article except as expressly provided in this subsection and Subsection (i) of this section. If such health maintenance organization performs utilization review as defined herein, it shall, as a condition of licensure:

(1) comply with this article, except Sections 3 and 10, and the commissioner shall promulgate rules for appropriate verification and enforcement of compliance. However, nothing in this article shall be construed to prohibit or limit the distribution of a proportion of the savings from the reduction or elimination of unnecessary medical services, treatment, supplies, confinements, or days of confinement in a health care facility through profit sharing, bonus, or withhold arrangements to participating physicians or participating health care providers for rendering health care services to enrollees; and

(2) submit to assessment of maintenance taxes under Article 20A.33, Texas Health Maintenance Organization Act (Article 20A.33, Vernon's Texas Insurance Code), to cover the costs of administering compliance of health maintenance organizations under this section.

(i) However, when … a health maintenance organization performs utilization review for a person or entity subject to this article other than one for which it is the payor, such … health maintenance organization shall be required to obtain a certificate under Section 3 of this article and comply with all the provisions of this article.

Revisor's Note

(1) Section 14(g), V.T.I.C. Article 21.58A, imposes certain duties "as a condition of licensure" on health maintenance organizations that perform utilization review. The revised law substitutes "as a condition of holding a certificate of authority to engage in the business of a health maintenance organization" for "as a condition of licensure" because under Section 843.071 of this code, a person is required to obtain a certificate of authority to operate as a health maintenance organization.

(2) Section 14(g)(1), V.T.I.C. Article 21.58A, refers to Section 10 of Article 21.58A. The revised law omits the reference because Section 10 was repealed by Chapter 703, Acts of the 77th Legislature, Regular Session, 2001.

(3) Section 14(g)(2), V.T.I.C. Article 21.58A, refers to the assessment of maintenance taxes under "Article 20A.33, Texas Health Maintenance Organization Act (Article 20A.33, Vernon's Texas Insurance Code)." V.T.I.C. Article 20A.33 was revised in various chapters in this code. The portions of Article 20A.33 relating to imposition of maintenance taxes on health maintenance organizations are revised as Chapter 258 of this code. The revised law is drafted accordingly.

(4) Section 14(i), V.T.I.C. Article 21.58A, requires a health maintenance organization that performs utilization review for certain persons or entities to obtain a certificate of registration under Section 3, Article 21.58A, revised in this chapter as Subchapter C. The revised law adds the phrase "[n]otwithstanding Subsection (c)(1)" to this provision to clarify that the relevant portion of Section 14(i), revised as Section 4201.057(e), is an exception to the exemption from the requirement to obtain a certificate of registration that is provided by Section 14(g)(1), Article 21.58A, revised in relevant part as Section 4201.057(c)(1).

Revised Law

Sec. 4201.058. INSURERS. (a) This chapter applies to an insurer subject to this code that delivers or issues for delivery a health insurance policy in this state except as expressly provided by this section. As a condition of holding a certificate of authority to engage in the business of insurance, an insurer that performs utilization review shall comply with this chapter, except Subchapter C. The insurer is subject to assessment of a maintenance tax under Chapter 257 to cover the costs of administering compliance with this subsection.

(b) The commissioner shall adopt rules for appropriate verification and enforcement of compliance with Subsection (a).

(c) Notwithstanding Subsection (a), an insurer subject to this code that performs utilization review for a person or entity subject to this chapter, other than a person or entity for which the insurer is the payor, must obtain a certificate of registration under Subchapter C and shall comply with all of the provisions of this chapter. (V.T.I.C. Art. 21.58A, Secs. 14(h), (i) (part).)

Source Law

(h) An insurer which delivers or issues for delivery a health insurance policy in Texas and is subject to this code is subject to this article except as expressly provided in this subsection and Subsection (i) of this section. If an insurer performs utilization review as defined herein it shall, as a condition of licensure, comply with this article, except Sections 3 and 10, and the commissioner shall promulgate rules for appropriate verification and enforcement of compliance. Such insurers shall be subject to assessment of maintenance tax under Article 4.17 of this code to cover the costs of administering compliance of insurers under this section.

(i) However, when an insurer subject to this code or … performs utilization review for a person or entity subject to this article other than one for which it is the payor, such insurer or … shall be required to obtain a certificate under Section 3 of this article and comply with all the provisions of this article.

Revisor's Note

(1) Section 14(h), V.T.I.C. Article 21.58A, imposes certain duties "as a condition of licensure" on certain insurers that perform utilization review. The revised law substitutes "[a]s a condition of holding a certificate of authority to engage in the business of insurance" for "[a]s a condition of licensure" because, under this code, an insurer is required to obtain a certificate of authority to engage in the business of insurance in this state.

(2) Section 14(h), V.T.I.C. Article 21.58A, refers to Section 10 of Article 21.58A. The revised law omits the reference for the reason stated in Revisor's Note (2) to Section 4201.057.

(3) Section 14(h), V.T.I.C. Article 21.58A, refers to the assessment of a maintenance tax under "Article 4.17 of this code." V.T.I.C. Article 4.17 was revised in various chapters in this code. The relevant provisions are revised in Chapter 257 of this code. The revised law is drafted accordingly.

(4) Section 14(i), V.T.I.C. Article 21.58A, requires an insurer that performs utilization review for certain persons or entities to obtain a certificate of registration under Section 3, Article 21.58A, revised in this chapter as Subchapter C. The revised law adds the phrase "[n]otwithstanding Subsection (a)" to this provision to clarify that the relevant portion of Section 14(i), revised as Section 4201.058(c), is an exception to the exemption from the requirement to obtain a certificate of registration that is provided by Section 14(h), Article 21.58A, revised in relevant part as Section 4201.058(a).

[Sections 4201.059-4201.100 reserved for expansion]

SUBCHAPTER C. CERTIFICATION

Revised Law

Sec. 4201.101. CERTIFICATE OF REGISTRATION REQUIRED. A utilization review agent may not conduct utilization review unless the commissioner issues a certificate of registration to the agent under this subchapter. (V.T.I.C. Art. 21.58A, Secs. 2 (part), 3(a).)

Source Law

Sec. 2. [In this article:]

…

(4) ["Certificate" means a certificate of registration] granted by the commissioner to a utilization review agent.

…

Sec. 3. (a) A utilization review agent may not conduct utilization review of health care provided in this state unless the commissioner has granted the utilization review agent a certificate pursuant to this article.

Revisor's Note

Section 3(a), V.T.I.C. Article 21.58A, refers to utilization review of "health care provided in this state." The revised law omits the quoted phrase because it duplicates the definition of "utilization review" in Section 2(20), V.T.I.C. Article 21.58A, revised in this chapter as Section 4201.002(13).

Revised Law

Sec. 4201.102. REQUIREMENTS FOR CERTIFICATION. (a) The commissioner may issue a certificate of registration only to an applicant who has met all the requirements of this chapter and all applicable rules adopted by the commissioner.

(b) As a condition of holding a certificate of registration or renewal of a certificate, a utilization review agent must maintain compliance with Subchapters D, E, and F. (V.T.I.C. Art. 21.58A, Secs. 3(b), 4(a).)

Source Law

[Sec. 3]

(b) The commissioner may only issue a certificate to an applicant that has met all the requirements of this article and all applicable rules and regulations of the commissioner.

Sec. 4. (a) As a condition of certification or renewal thereof, a utilization review agent shall be required to maintain compliance with the provisions of this section.

Revised Law

Sec. 4201.103. CERTIFICATE RENEWAL. Certification may be renewed biennially by filing, not later than March 1, a renewal form with the commissioner accompanied by a fee in an amount set by the commissioner. (V.T.I.C. Art. 21.58A, Sec. 3(d).)

Source Law

(d) Certification may be renewed biennially by filing, not later than March 1, a renewal form with the commissioner accompanied by a renewal fee in an amount set by the commissioner.

Revised Law

Sec. 4201.104. CERTIFICATION AND RENEWAL FORMS. (a) The commissioner shall promulgate forms to be filed under this subchapter for initial certification and for a renewal certificate of registration. The form for initial certification must require:

(1) the utilization review agent's name, address, telephone number, and normal business hours;

(2) the name and address of an agent for service of process in this state;

(3) a summary of the utilization review plan;

(4) information concerning the categories of personnel who will perform utilization review for the agent;

(5) a copy of the procedures established under Subchapter H for the appeal of an adverse determination;

(6) a certification that the agent will comply with this chapter; and

(7) a copy of the procedures for resolving oral or written complaints initiated by enrollees, patients, or health care providers as required by Section 4201.204.

(b) The commissioner may not require that the summary of the utilization review plan include proprietary details. (V.T.I.C. Art. 21.58A, Sec. 3(e).)

Source Law

(e) The commissioner shall promulgate certification and renewal forms to be filed under this section. The form for initial certification must require the following:

(1) the entity's name, address, telephone number, and normal business hours;

(2) the name and address of an agent for service of process in this state;

(3) a summary of the utilization review plan, but in no event shall proprietary details be subject to inclusion in the summary;

(4) information concerning the personnel categories that will perform utilization review for the utilization review agent;

(5) a copy of the procedure established by the utilization review agent as required by this article for appeal of an adverse determination;

(6) a certification that the utilization review agent will comply with the provisions of this article; and

(7) a copy of the procedures for handling oral and written complaints by enrollees, patients, or health care providers.

Revisor's Note

(1) Section 3(e)(5), V.T.I.C. Article 21.58A, refers to procedures for appeal of an adverse determination established by a utilization review agent. For the reader's convenience, the revised law adds a cross-reference to Subchapter H because that subchapter, which is derived from Section 6, V.T.I.C. Article 21.58A, requires those procedures.

(2) Section 3(e)(7), V.T.I.C. Article 21.58A, refers to procedures for handling certain complaints concerning utilization review. For the reader's convenience, the revised law adds a cross-reference to Section 4201.204 because that section, which is derived from Section 4(m), V.T.I.C. Article 21.58A, requires a utilization review agent to establish those procedures.

Revised Law

Sec. 4201.105. FEES. The commissioner shall establish, administer, and enforce the fees for initial certification and certification renewal in amounts that do not exceed the amounts necessary to cover the cost of administering this chapter. (V.T.I.C. Art. 21.58A, Sec. 3(f).)

Source Law

(f) The commissioner shall establish, administer, and enforce the certification and renewal fees under this section in amounts not greater than that necessary to cover the cost of administration of this article.

Revised Law

Sec. 4201.106. CERTIFICATE NOT TRANSFERABLE. A certificate of registration is not transferable. (V.T.I.C. Art. 21.58A, Sec. 3(c).)

Source Law

Revised Law

Sec. 4201.107. REPORTING MATERIAL CHANGES. A utilization review agent shall report any material change to the information disclosed in a form filed under this subchapter not later than the 30th day after the date the change takes effect. (V.T.I.C. Art. 21.58A, Sec. 3(g).)

Source Law

(g) A utilization review agent shall report any material changes in the information in a certification or renewal form filed under this section not later than the 30th day after the date on which the change takes effect.

Revisor's Note

Section 3(g), V.T.I.C. Article 21.58A, refers to a certification or renewal form filed under "this section," meaning Section 3, V.T.I.C. Article 21.58A. Although this subchapter contains provisions derived from other sections of Article 21.58A, the revised law substitutes "this subchapter" for "this section" because the only provisions in this subchapter that relate to filing forms are derived from Section 3.

Revised Law

Sec. 4201.108. LIST OF UTILIZATION REVIEW AGENTS. (a) The commissioner shall maintain and update monthly a list of each utilization review agent to whom a certificate of registration has been issued and the renewal date of the certificate.

(b) The commissioner shall provide the list at cost to each individual or organization requesting the list. (V.T.I.C. Art. 21.58A, Sec. 12.)

Source Law

Sec. 12. The commissioner shall maintain and update monthly a list of utilization review agents issued certificates and the renewal date for those certificates. The commissioner shall provide the list at cost to all individuals or organizations requesting the list.

[Sections 4201.109-4201.150 reserved for expansion]

SUBCHAPTER D. UTILIZATION REVIEW: GENERAL STANDARDS

Revised Law

Sec. 4201.151. UTILIZATION REVIEW PLAN. A utilization review agent's utilization review plan, including reconsideration and appeal requirements, must be reviewed by a physician and conducted in accordance with standards developed with input from appropriate health care providers and approved by a physician. (V.T.I.C. Art. 21.58A, Sec. 4(b).)

Source Law

(b) The utilization review plan, including reconsideration and appeal requirements, shall be reviewed by a physician and conducted in accordance with standards developed with input from appropriate health care providers and approved by a physician.

Revised Law

Sec. 4201.152. UTILIZATION REVIEW UNDER DIRECTION OF PHYSICIAN. A utilization review agent shall conduct utilization review under the direction of a physician licensed to practice medicine by a state licensing agency in the United States. (V.T.I.C. Art. 21.58A, Sec. 4(h).)

Source Law

(h) Utilization review conducted by a utilization review agent shall be under the direction of a physician licensed to practice medicine by a state licensing agency in the United States.

Revised Law

Sec. 4201.153. SCREENING CRITERIA AND REVIEW PROCEDURES. (a) A utilization review agent shall use written medically acceptable screening criteria and review procedures that are established and periodically evaluated and updated with appropriate involvement from physicians, including practicing physicians, dentists, and other health care providers.

(b) A utilization review determination shall be made in accordance with currently accepted medical or health care practices, taking into account special circumstances of the case that may require deviation from the norm stated in the screening criteria.

(1) objective;

(2) clinically valid;

(3) compatible with established principles of health care; and

(4) flexible enough to allow a deviation from the norm when justified on a case-by-case basis.

(d) Screening criteria must be used to determine only whether to approve the requested treatment. A denial of requested treatment must be referred to an appropriate physician, dentist, or other health care provider to determine medical necessity. (V.T.I.C. Art. 21.58A, Sec. 4(i) (part).)

Source Law

(i) Each utilization review agent shall utilize written medically acceptable screening criteria and review procedures which are established and periodically evaluated and updated with appropriate involvement from physicians, including practicing physicians, dentists, and other health care providers. Utilization review decisions shall be made in accordance with currently accepted medical or health care practices, taking into account special circumstances of each case that may require deviation from the norm stated in the screening criteria. Screening criteria must be objective, clinically valid, compatible with established principles of health care, and flexible enough to allow deviations from the norms when justified on a case-by-case basis. Screening criteria must be used to determine only whether to approve the requested treatment. Denials must be referred to an appropriate physician, dentist, or other health care provider to determine medical necessity. …

Revised Law

Sec. 4201.154. REVIEW AND INSPECTION OF SCREENING CRITERIA AND REVIEW PROCEDURES. (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 authority of this section, Section 4201.153, and this chapter is confidential and privileged and is not subject to Chapter 552, Government Code, or to subpoena except to the extent necessary for the commissioner to enforce this chapter. (V.T.I.C. Art. 21.58A, Sec. 4(i) (part).)

Source Law

(i) … Such written screening criteria and review procedures shall be available for review and inspection to determine appropriateness and compliance as deemed necessary by the commissioner and copying as necessary for the commissioner to carry out his or her lawful duties under this code, provided, however, that any information obtained or acquired under the authority of this subsection and article is confidential and privileged and not subject to the open records law or subpoena except to the extent necessary for the commissioner to enforce this article.

Revisor's Note

Section 4(i), V.T.I.C. Article 21.58A, refers to the "lawful duties" of the commissioner of insurance. The revised law omits "lawful" as unnecessary because all of a public official's duties are imposed by law.

Revised Law

Sec. 4201.155. LIMITATION ON NOTICE REQUIREMENTS AND REVIEW PROCEDURES. 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. (V.T.I.C. Art. 21.58A, Sec. 4(d).)

Source Law

(d) A utilization review agent shall not set or impose any notice or other review procedures contrary to the requirements of the health insurance policy or health benefit plan.

[Sections 4201.156-4201.200 reserved for expansion]

SUBCHAPTER E. UTILIZATION REVIEW: RELATIONS WITH PATIENTS AND HEALTH CARE PROVIDERS

Revised Law

Sec. 4201.201. REPETITIVE CONTACTS WITH HEALTH CARE PROVIDER OR PATIENT; FREQUENCY OF REVIEWS. 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. (V.T.I.C. Art. 21.58A, Sec. 4(j).)

Source Law

(j) A utilization review agent may not engage in unnecessary or unreasonable repetitive contacts with the health care provider or patient and 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.

Revised Law

Sec. 4201.202. OBSERVING OR PARTICIPATING IN PATIENT'S CARE. (a) Unless approved for an individual patient by the provider of record or modified by contract, a utilization review agent shall be prohibited from observing, participating in, or otherwise being present during a patient's examination, treatment, procedure, or therapy.

(b) This subchapter, Subchapters D and F, and Section 4201.102(b), may not be construed to otherwise limit or deny contact with a patient for purposes of conducting utilization review unless otherwise specifically prohibited by law. (V.T.I.C. Art. 21.58A, Sec. 4(e).)

Source Law

(e) Unless approved for an individual patient by the provider of record or modified by contract, a utilization review agent shall be prohibited from observing, participating in, or otherwise being present during a patient's examination, treatment, procedure, or therapy. In no event shall this section otherwise be construed to limit or deny contact with a patient for purposes of conducting utilization review unless otherwise specifically prohibited by law.

Revised Law

Sec. 4201.203. MENTAL HEALTH THERAPY. (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 summary. (V.T.I.C. Art. 21.58A, Sec. 4(o).)

Source Law

(o) 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. Notwithstanding this subsection, a utilization review agent may require submission of a patient's medical record summary.

Revised Law

Sec. 4201.204. COMPLAINT SYSTEM. (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 complainant within 30 days.

(c) A utilization review agent shall submit to the commissioner a summary report of all complaints at the times and in the form specified by the commissioner. The agent shall allow the commissioner to examine the complaints and relevant documents at any time.

(d) A utilization review agent shall maintain a record of each complaint until the third anniversary of the date the complainant filed the complaint. (V.T.I.C. Art. 21.58A, Sec. 4(m).)

Source Law

(m) 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 and shall maintain records of such complaints for three years from the time the complaints are filed. The complaint procedure shall include a written response to the complainant by the agent within 30 days. The utilization review agent shall submit to the commissioner a summary report of all complaints at such times and in such forms as the commissioner may require and shall permit the commissioner to examine the complaints and all relevant documents at any time.

Revised Law

Sec. 4201.205. DESIGNATED INITIAL CONTACT. (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 are not designated under this section under circumstances in which:

(1) a review might otherwise be unreasonably delayed; or

(2) the designated individual is unable to provide the necessary data or information that the agent requests. (V.T.I.C. Art. 21.58A, Sec. 4(g).)

Source Law

(g) A health care provider may designate one or more individuals as the initial contact or contacts for utilization review agents seeking routine information or data. In no event shall the designation of such an individual or individuals preclude a utilization review agent or medical advisor from contacting a health care provider or others in his or her employ where a review might otherwise be unreasonably delayed or where the designated individual is unable to provide the necessary information or data requested by the utilization review agent.

Revised Law

Sec. 4201.206. OPPORTUNITY TO DISCUSS TREATMENT BEFORE ADVERSE DETERMINATION. Subject to the notice requirements of Subchapter G, before a utilization review agent who questions the medical necessity or appropriateness of a health care service issues an adverse determination, the agent shall provide the health care provider who ordered the service a reasonable opportunity to discuss with a physician the patient's treatment plan and the clinical basis for the agent's determination. (V.T.I.C. Art. 21.58A, Sec. 4(k).)

Source Law

(k) Subject to the notice requirements of Section 5 of this article, in any instance where the utilization review agent is questioning the medical necessity or appropriateness of health care services, the health care provider who ordered the services shall be afforded a reasonable opportunity to discuss the plan of treatment for the patient and the clinical basis for the utilization review agent's decision with a physician prior to issuance of an adverse determination.

Revised Law

Sec. 4201.207. CHARGES BY HEALTH CARE PROVIDER FOR PROVIDING MEDICAL INFORMATION. (a) Unless precluded or modified by contract, a utilization review agent shall reimburse a health care provider for the reasonable costs of providing medical information in writing, including the costs of copying and transmitting requested patient records or other documents.

(b) A health care provider's charges for providing medical information to a utilization review agent may not:

(1) exceed the cost of copying records as set by rules adopted by the Texas Workers' Compensation Commission; or

(2) include any costs otherwise recouped as part of the charges for health care. (V.T.I.C. Art. 21.58A, Sec. 4(l).)

Source Law

(l) Unless precluded or modified by contract, a utilization review agent shall reimburse health care providers for the reasonable costs for providing medical information in writing, including copying and transmitting any requested patient records or other documents. A health care provider's charges for providing medical information to a utilization review agent shall not exceed the cost of copying set by rule of the Texas Workers' Compensation Commission for records and may not include any costs that are otherwise recouped as a part of the charge for health care.

[Sections 4201.208-4201.250 reserved for expansion]

SUBCHAPTER F. UTILIZATION REVIEW: PERSONNEL

Revised Law

Sec. 4201.251. DELEGATION OF UTILIZATION REVIEW. 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, including the conduct of those to whom utilization review has been delegated. (V.T.I.C. Art. 21.58A, Sec. 4(n).)

Source Law

(n) The utilization review agent may delegate utilization review to qualified personnel in the hospital or health care facility where the health care services were or are to be provided. However, such delegation shall not relieve the utilization review agent of full responsibility for compliance with this article, including the conduct of those to whom utilization review has been delegated.

Revised Law

Sec. 4201.252. PERSONNEL. (a) Personnel employed by or under contract with a utilization review agent to perform utilization review must be appropriately trained and qualified.

(b) Personnel, other than a physician, who obtain oral or written information directly from a patient's physician or other health care provider regarding the patient's specific medical condition, diagnosis, or treatment options or protocols must be a nurse, physician assistant, or other health care provider qualified to provide the requested service.

(c) This section may not be interpreted to require personnel who perform clerical or administrative tasks to have the qualifications prescribed by this section. (V.T.I.C. Art. 21.58A, Sec. 4(c).)

Source Law

(c) Personnel employed by or under contract with the utilization review agent to perform utilization review shall be appropriately trained and qualified. Personnel who obtain information regarding a patient's specific medical condition, diagnosis, and treatment options or protocols directly from the physician or health care provider, either orally or in writing, and who are not physicians shall be nurses, physician assistants, or health care providers qualified to provide the service requested by the provider. This provision shall not be interpreted to require such qualifications for personnel who perform clerical or administrative tasks.

Revised Law

Sec. 4201.253. PROHIBITED BASES FOR EMPLOYMENT, COMPENSATION, EVALUATIONS, OR PERFORMANCE STANDARDS. 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 lengths of stay, benefits, services, or charges, or the number or frequency of telephone calls or other contacts with health care providers or patients, that are inconsistent with this chapter. (V.T.I.C. Art. 21.58A, Sec. 4(f).)

Source Law

(f) A utilization review agent may not permit or provide compensation or any thing of value to its employees or agents, condition employment of its employee or agent evaluations, or set its employee or agent performance standards, based on the amount of volume of adverse determinations, reductions or limitations on lengths of stay, benefits, services, or charges or on the number or frequency of telephone calls or other contacts with health care providers or patients, which are inconsistent with the provisions of this article.

[Sections 4201.254-4201.300 reserved for expansion]

SUBCHAPTER G. NOTICE OF DETERMINATIONS

Revised Law

Sec. 4201.301. GENERAL DUTY TO NOTIFY. 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. (V.T.I.C. Art. 21.58A, Sec. 5(a).)

Source Law

Sec. 5. (a) A utilization review agent shall notify the enrollee or a person acting on behalf of the enrollee and the enrollee's provider of record of a determination made in a utilization review.

Revised Law

Sec. 4201.302. GENERAL TIME FOR NOTICE. 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. (V.T.I.C. Art. 21.58A, Sec. 5(b).)

Source Law

(b) The notification required by this section must be mailed or otherwise transmitted not later than two working days after the date of the request for utilization review and all information necessary to complete the review is received by the agent.

Revised Law

Sec. 4201.303. ADVERSE DETERMINATION: CONTENTS OF NOTICE. (a) Notice of an adverse determination must include:

(1) the principal reasons for the adverse determination;

(2) the clinical basis for the adverse determination;

(3) a description of or the source of the screening criteria used as guidelines in making the adverse determination; and

(4) a description of the procedure for the complaint and appeal process, including notice to the enrollee of the enrollee's right to appeal an adverse determination to an independent review organization and of the procedures to obtain that review.

(b) For an enrollee who has a life-threatening condition, the notice required by Subsection (a)(4) must include a description of the enrollee's right to an immediate review by an independent review organization and of the procedures to obtain that review. (V.T.I.C. Art. 21.58A, Sec. 5(c).)

Source Law

(1) the principal reasons for the adverse determination;

(2) the clinical basis for the adverse determination;

(3) a description or the source of the screening criteria that were utilized as guidelines in making the determination; and

(4) a description of the procedure for the complaint and appeal process, including:

(A) notification to the enrollee of the enrollee's right to appeal an adverse determination to an independent review organization;

(B) notification to the enrollee of the procedures for appealing an adverse determination to an independent review organization; and

(C) notification to an enrollee who has a life-threatening condition of the enrollee's right to an immediate review by an independent review organization and the procedures to obtain that review.

Revised Law

Sec. 4201.304. TIME FOR NOTICE OF ADVERSE DETERMINATION. 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 a letter within three working days notifying the patient and the provider of record of the adverse determination;

(2) with respect to a patient who is not hospitalized at the time of the adverse determination, within three working days in writing to the provider of record and the patient; or

(3) within the time appropriate to the circumstances relating to the delivery of the services to the patient and to the patient's condition, provided that when denying poststabilization care subsequent to emergency treatment as requested by a treating physician or other health care provider, the agent shall provide the notice to the treating physician or other health care provider not later than one hour after the time of the request. (V.T.I.C. Art. 21.58A, Sec. 5(d).)

Source Law

(d) The notification of adverse determination required by this section shall be provided by the utilization review agent:

(1) within one working day by telephone or electronic transmission to the provider of record in the case of a patient who is hospitalized at the time of the adverse determination, to be followed by a letter notifying the patient and the provider of record of an adverse determination within three working days;

(2) within three working days in writing to the provider of record and the patient if the patient is not hospitalized at the time of the adverse determination; or

(3) within the time appropriate to the circumstances relating to the delivery of the services and the condition of the patient, but in no case to exceed one hour from notification when denying poststabilization care subsequent to emergency treatment as requested by a treating physician or provider. In such circumstances, notification shall be provided to the treating physician or health care provider.

[Sections 4201.305-4201.350 reserved for expansion]

SUBCHAPTER H. APPEAL OF ADVERSE DETERMINATION

Revised Law

Sec. 4201.351. COMPLAINT AS APPEAL. For purposes of this subchapter, a complaint filed concerning dissatisfaction or disagreement with an adverse determination constitutes an appeal of that adverse determination. (V.T.I.C. Art. 21.58A, Sec. 6(a) (part).)

Source Law

Sec. 6. (a) … For the purposes of this section, a complaint filed concerning dissatisfaction or disagreement with an adverse determination constitutes an appeal of that adverse determination.

Revised Law

Sec. 4201.352. WRITTEN DESCRIPTION OF APPEAL PROCEDURES. A utilization review agent shall maintain and make available a written description of the procedures for appealing an adverse determination. (V.T.I.C. Art. 21.58A, Sec. 6(a) (part).)

Source Law

Sec. 6. (a) A utilization review agent shall maintain and make available a written description of appeal procedures involving an adverse determination… .

Revised Law

Sec. 4201.353. APPEAL PROCEDURES MUST BE REASONABLE. The procedures for appealing an adverse determination must be reasonable. (V.T.I.C. Art. 21.58A, Sec. 6(b) (part).)

Source Law

(b) The procedures for appeals must be reasonable and … .

Revised Law

Sec. 4201.354. PERSONS OR ENTITIES WHO MAY APPEAL. 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. (V.T.I.C. Art. 21.58A, Sec. 6(b) (part).)

Source Law

(b) The procedures for appeals … must include the following:

(1) a provision that an enrollee, a person acting on behalf of the enrollee, or the enrollee's physician or health care provider may appeal the adverse determination orally or in writing; … .

Revised Law

Sec. 4201.355. ACKNOWLEDGMENT OF APPEAL. (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 subchapter; and

(2) the documents that the appealing party must submit for review.

(c) When a utilization review agent receives an oral appeal of an adverse determination, the agent shall send a one-page appeal form to the appealing party. (V.T.I.C. Art. 21.58A, Sec. 6(b) (part).)

Source Law

(b) The procedures for appeals … must include the following:

…

(2) a provision that, within five working days from receipt of the appeal, the utilization review agent shall send to the appealing party a letter acknowledging the date of the utilization review agent's receipt of the appeal. The letter must also include the provisions listed in this subsection and a list of the documents that the appealing party must submit for review by the utilization review agent. When the utilization review agent receives an oral appeal of adverse determination, the utilization review agent shall send a one-page appeal form to the appealing party; … .

Revised Law

Sec. 4201.356. DECISION BY PHYSICIAN REQUIRED; SPECIALTY REVIEW. (a) The procedures for appealing an adverse determination must provide that a physician 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 denied the enrollee's health care provider states in writing good cause for having a particular type of specialty provider review the case, a health care provider who is of the same or a similar specialty as the health care provider who would typically manage the medical or dental condition, procedure, or treatment under consideration for review shall review the decision denying the appeal. The specialty review must be completed within 15 working days of the date the health care provider's request for specialty review is received. (V.T.I.C. Art. 21.58A, Sec. 6(b) (part).)

Source Law

(b) The procedures for appeals … must include the following:

…

(3) a provision that appeal decisions shall be made by a physician, provided that, if the appeal is denied and within 10 working days the health care provider sets forth in writing good cause for having a particular type of a specialty provider review the case, the denial shall be reviewed by a health care provider in the same or similar specialty as typically manages the medical or dental condition, procedure, or treatment under discussion for review of the adverse determination, and that specialty review shall be completed within 15 working days of receipt of the request; … .

Revised Law

Sec. 4201.357. EXPEDITED APPEAL FOR DENIAL OF EMERGENCY CARE OR CONTINUED HOSPITALIZATION. (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 or a denial of continued hospitalization. That procedure must include a review by a health care provider who:

(1) has not previously reviewed the case; and

(2) is of the same or a similar specialty as the health care provider who would typically manage the medical or dental condition, procedure, or treatment under review in the appeal.

(b) The time for resolution of an expedited appeal under this section shall be based on the medical or dental immediacy of the condition, procedure, or treatment under review, provided that the resolution of the appeal may not exceed one working day from the date all information necessary to complete the appeal is received. (V.T.I.C. Art. 21.58A, Sec. 6(b) (part).)

Source Law

(b) The procedures for appeals … must include the following:

…

(4) in addition to the written appeal, a method for an expedited appeal procedure for emergency care denials and denials of continued stays for hospitalized patients. That procedure must include a review by a health care provider who has not previously reviewed the case and who is of the same or a similar specialty as typically manages the medical condition, procedure, or treatment under review. The time frame in which the appeal must be completed shall be based on the medical or dental immediacy of the condition, procedure, or treatment, but may not exceed one working day from the date all information necessary to complete the appeal is received; … .

Revisor's Note

Section 6(b)(4), V.T.I.C. Article 21.58A, refers to a health care provider who is of the same or a similar specialty as the health care provider who would typically manage the "medical condition, procedure, or treatment under review." The revised law substitutes "medical or dental" for "medical" because it is clear from the context of the source law, including the reference in the source law to the "medical or dental" immediacy of the condition, that the case under review may involve a medical or dental condition, procedure, or treatment.

Revised Law

Sec. 4201.358. RESPONSE LETTER TO INTERESTED PERSONS. 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 provider. (V.T.I.C. Art. 21.58A, Sec. 6(b) (part).)

Source Law

(b) The procedures for appeals … must include the following:

…

(5) a provision that after the utilization review agent has sought review of the appeal of the adverse determination, the utilization review agent shall issue a response letter to the patient or a person acting on behalf of the patient, and the patient's physician or health care provider, explaining the resolution of the appeal; and … .

Revised Law

Sec. 4201.359. NOTICE OF APPEAL. (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 clear and concise statement of:

(1) the clinical basis for the denial;

(2) the specialty of the physician or other health care provider making the denial; and

(3) the appealing party's right to seek review of the denial by an independent review organization under Subchapter I and the procedures for obtaining that review. (V.T.I.C. Art. 21.58A, Sec. 6(b) (part).)

Source Law

(b) The procedures for appeals … must include the following:

…

(6) written notification to the appealing party of the determination of the appeal, as soon as practical, but in no case later than the 30th calendar day after the date the utilization agent receives the appeal. If the appeal is denied, the written notification shall include a clear and concise statement of:

(A) the clinical basis for the appeal's denial;

(B) the specialty of the physician or other health care provider making the denial; and

(C) notice of the appealing party's right to seek review of the denial by an independent review organization under Section 6A of this article and the procedures for obtaining that review.

Revisor's Note

Section 6(b)(6)(C), V.T.I.C. Article 21.58A, refers to a review by an independent review organization under Section 6A, V.T.I.C. Article 21.58A. Section 6A is revised in this chapter in Subchapter I. Although the provision revised as Section 4201.402(b), which is contained in Subchapter I, is not derived from Section 6A, it is appropriate throughout this chapter to substitute references to Subchapter I in its entirety for references to Section 6A because the provision revised as Section 4201.402(b) applies certain rules and standards to a utilization review agent who provides confidential information to a utilization review organization, and that provision would apply by its own terms in an appeal to an independent review organization conducted under Section 6A.

Revised Law

Sec. 4201.360. IMMEDIATE APPEAL TO INDEPENDENT REVIEW ORGANIZATION IN LIFE-THREATENING CIRCUMSTANCES. 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. (V.T.I.C. Art. 21.58A, Sec. 6(c).)

Source Law

(c) Notwithstanding this article or any other law, in a circumstance involving an enrollee's life-threatening condition, the enrollee is entitled to an immediate appeal to an independent review organization as provided by Section 6A of this article and is not required to comply with procedures for an internal review of the utilization review agent's adverse determination.

[Sections 4201.361-4201.400 reserved for expansion]

SUBCHAPTER I. INDEPENDENT REVIEW OF ADVERSE DETERMINATION

Revised Law

Sec. 4201.401. REVIEW BY INDEPENDENT REVIEW ORGANIZATION; COMPLIANCE WITH INDEPENDENT DETERMINATION. (a) A utilization review agent shall allow any party whose appeal of an adverse determination is denied by the agent to seek review of that determination by an independent review organization assigned to the appeal in accordance with Chapter 4202.

(b) The utilization review agent shall comply with the independent review organization's determination regarding the medical necessity or appropriateness of health care items and services for an enrollee. (V.T.I.C. Art. 21.58A, Sec. 6A (part).)

Source Law

Sec. 6A. A utilization review agent shall:

(1) permit any party whose appeal of an adverse determination is denied by the utilization review agent to seek review of that determination by an independent review organization assigned to the appeal in accordance with Article 21.58C of this code;

…

(3) comply with the independent review organization's determination with respect to the medical necessity or appropriateness of health care items and services for an enrollee; and … .

Revised Law

Sec. 4201.402. INFORMATION PROVIDED TO INDEPENDENT REVIEW ORGANIZATION. (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 in making the determination to be reviewed;

(D) any documents and other written information submitted to the agent in support of the appeal; and

(2) a list of each physician or other health care provider who:

(A) has provided care to the enrollee; and

(B) may have medical records relevant to the appeal.

(b) A utilization review agent may provide confidential information in the custody of the agent to an independent review organization, subject to rules and standards adopted by the commissioner under Chapter 4202. (V.T.I.C. Art. 21.58A, Secs. 6A (part); 8(f), as added Acts 75th Leg., R.S., Ch. 163.)

Source Law

Sec. 6A. A utilization review agent shall:

…

(2) provide to the appropriate independent review organization not later than the third business day after the date that the utilization review agent receives a request for review a copy of:

(A) any medical records of the enrollee that are relevant to the review;

(B) any documents used by the plan in making the determination to be reviewed by the organization;

(D) any documentation and written information submitted to the utilization review agent in support of the appeal; and

(E) a list of each physician or health care provider who has provided care to the enrollee and who may have medical records relevant to the appeal; … .

[Sec. 8]

(f) Confidential information in the custody of a utilization review agent may be provided to an independent review organization, subject to rules and standards adopted by the commissioner under Article 21.58C of this code.

Revisor's Note

Section 6A(2)(C), V.T.I.C. Article 21.58A, refers to the "written notification described by Section 6(b)(5) of this article." V.T.I.C. Section 6A was enacted by Chapter 163, Acts of the 75th Legislature, Regular Session, 1997. That act also amended Section 6(b)(5), Article 21.58A, in part to reflect an appealing party's right to seek independent review under Section 6A of an adverse utilization review determination. During the same legislative session, the substance of Section 6(b)(5) was amended again and renumbered as Section 6(b)(6) by Chapter 1025, Acts of the 75th Legislature, Regular Session, 1997. In 1999, Section 6 was amended and reenacted by Chapter 1456, Acts of the 76th Legislature, Regular Session, to reflect the amendments made to that section by Chapters 163 and 1025, Acts of the 75th Legislature, Regular Session, 1997. In that reenactment, the notice provision to which Section 6A(2)(C) refers was renumbered as Section 6(b)(6). Thus, the correct citation to the referenced written notice is Section 6(b)(6), revised in this chapter as Section 4201.359, not Section 6(b)(5), revised in this chapter as Section 4201.358. The revised law is drafted accordingly.

Revised Law

Sec. 4201.403. PAYMENT FOR INDEPENDENT REVIEW. A utilization review agent shall pay for an independent review conducted under this subchapter. (V.T.I.C. Art. 21.58A, Sec. 6A (part).)

Source Law

Sec. 6A. A utilization review agent shall:

…

(4) pay for the independent review.

[Sections 4201.404-4201.450 reserved for expansion]

SUBCHAPTER J. SPECIALTY UTILIZATION REVIEW AGENTS

Revised Law

Sec. 4201.451. DEFINITION. 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. (V.T.I.C. Art. 21.58A, Sec. 14(j) (part).)

Source Law

(j) … For purposes of this subsection, a specialty utilization review agent means a utilization review agent that conducts utilization review for specialty health care services, including but not limited to dentistry, chiropractic, or physical therapy… .

Revisor's Note

Section 14(j), V.T.I.C. Article 21.58A, refers to "including but not limited to." The revised law omits "but not limited to" for the reason stated in Revisor's Note (5) to Section 4201.002.

Revised Law

Sec. 4201.452. INAPPLICABILITY OF CERTAIN OTHER LAW. A specialty utilization review agent is not subject to Section 4201.151, 4201.152, 4201.206, 4201.252, or 4201.356. (V.T.I.C. Art. 21.58A, Sec. 14(j) (part).)

Source Law

(j) A specialty utilization review agent is not subject to Section 4(b), (c), (h), or (k) or Section 6(b)(3) of this article… .

Revised Law

Sec. 4201.453. UTILIZATION REVIEW PLAN. A specialty utilization review agent's utilization review plan, including reconsideration and appeal requirements, must be reviewed by a health care provider of the appropriate specialty and conducted in accordance with standards developed with input from a health care provider of the appropriate specialty. (V.T.I.C. Art. 21.58A, Sec. 14(j) (part).)

Source Law

(j) … A specialty utilization review agent shall comply with the following requirements:

(1) the utilization review plan, including reconsideration and appeal requirements, shall be reviewed by a health care provider of the appropriate specialty and conducted in accordance with standards developed with input from a health care provider of the appropriate specialty; … .

Revised Law

Sec. 4201.454. UTILIZATION REVIEW UNDER DIRECTION OF PROVIDER OF SAME SPECIALTY. 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 by a state licensing agency in the United States. (V.T.I.C. Art. 21.58A, Sec. 14(j) (part).)

Source Law

(j) … A specialty utilization review agent shall comply with the following requirements:

…

(3) utilization review conducted by a specialty utilization review agent shall be conducted under the direction of a health care provider of the same specialty and shall be licensed or otherwise authorized to provide the specialty health care service by a state licensing agency in the United States; … .

Revised Law

Sec. 4201.455. PERSONNEL. (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.

(b) Personnel who obtain oral or written information directly from a physician or other health care provider must be a nurse, physician assistant, or other health care provider of the same specialty as the agent and who are licensed or otherwise authorized to provide the specialty health care service by a state licensing agency in the United States.

(c) This section does not require personnel who perform only clerical or administrative tasks to have the qualifications prescribed by this section. (V.T.I.C. Art. 21.58A, Sec. 14(j) (part).)

Source Law

(j) … A specialty utilization review agent shall comply with the following requirements:

…

(2) personnel employed by or under contract with a specialty utilization review agent to perform utilization review shall be appropriately trained and qualified. Personnel who obtain information directly from the physician or health care provider, either orally or in writing, shall be nurses, physician assistants, or other health care providers of the same specialty as the utilization review agent and who are licensed or otherwise authorized to provide the specialty health care service by a state licensing agency in the United States, except that this provision does not require those qualifications for personnel who perform solely clerical or administrative tasks; … .

Revised Law

Sec. 4201.456. OPPORTUNITY TO DISCUSS TREATMENT BEFORE ADVERSE DETERMINATION. Subject to the notice requirements of Subchapter G, before a specialty utilization review agent who questions the medical necessity or appropriateness of a health care service issues an adverse determination, the agent shall provide the health care provider who ordered the service a reasonable opportunity to discuss the patient's treatment plan and the clinical basis for the agent's determination with a health care provider who is of the same specialty as the agent. (V.T.I.C. Art. 21.58A, Sec. 14(j) (part).)

Source Law

(j) … A specialty utilization review agent shall comply with the following requirements:

…

(4) subject to the notice requirements of Section 5 of this article, in any instance where the specialty utilization review agent questions the medical necessity or appropriateness of health care services, the health care provider who ordered the services shall, prior to the issuance of an adverse determination, be afforded a reasonable opportunity to discuss the plan of treatment for the patient and the clinical basis for the decision of the utilization review agent with a health care provider of the same specialty as the utilization review agent; and … .

Revised Law

Sec. 4201.457. APPEAL DECISIONS. 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 in the appeal. (V.T.I.C. Art. 21.58A, Sec. 14(j) (part).)

Source Law

(j) … A specialty utilization review agent shall comply with the following requirements:

…

(5) appeal decisions shall be made by a physician or health care provider in the same or a similar specialty as typically manages the medical, dental, or specialty condition, procedure, or treatment under discussion for review of the adverse determination.

Revisor's Note

Section 14(j)(5), V.T.I.C. Article 21.58A, refers to appeal decisions made by health care providers in the "same or a similar specialty as typically manages the medical, dental, or specialty condition, procedure, or treatment." The revised law omits the references to "medical" and "dental" because those terms are included within the meaning of specialty health care services subject to specialty utilization review as described by other provisions of Section 14(j), Article 21.58A, revised in this chapter as Section 4201.451.

[Sections 4201.458-4201.500 reserved for expansion]

SUBCHAPTER K. CLAIMS REVIEW OF MEDICAL NECESSITY

AND APPROPRIATENESS

Revised Law

Sec. 4201.501. RETROSPECTIVE REVIEW OF MEDICAL NECESSITY AND APPROPRIATENESS. (a) A retrospective review of the medical necessity and appropriateness of a health care service made under a health insurance policy or health benefit plan shall be based on written screening criteria established and periodically updated with appropriate involvement from physicians, including practicing physicians, and other health care providers.

(b) A payor's system for retrospective review of medical necessity and appropriateness under this section must be under the direction of a physician. (V.T.I.C. Art. 21.58A, Sec. 11(a).)

Source Law

Sec. 11. (a) When a retrospective review of the medical necessity and appropriateness of health care service is made under a health insurance policy or plan: (1) such retrospective review shall be based on written screening criteria established and periodically updated with appropriate involvement from physicians, including practicing physicians, and other health care providers; and (2) the payor's system for such retrospective review of medical necessity and appropriateness shall be under the direction of a physician.

Revisor's Note

Section 11(a), V.T.I.C. Article 21.58A, refers to a "health insurance policy or plan." The revised law substitutes "health benefit plan" for "plan" for the reason stated in Revisor's Note (7) to Section 4201.002.

Revised Law

Sec. 4201.502. APPEALS OF RETROSPECTIVE ADVERSE DETERMINATIONS. (a) When an adverse determination is made under a health insurance policy or health benefit plan based on a retrospective review of the medical necessity and appropriateness of the allocation of health care resources and services, the payor shall provide the health care provider with the opportunity to appeal the determination in the same manner as provided to the enrollee, with the enrollee's consent to act on the enrollee's behalf. In no event shall a health care provider be precluded from appeal if the enrollee is not reasonably available or competent to consent.

(b) The appeal does not imply or confer on a health care provider any contractual right with respect to the enrollee's health insurance policy or health benefit plan that the health care provider does not otherwise have. (V.T.I.C. Art. 21.58A, Sec. 11(b).)

Source Law

(b) When an adverse determination is made under a health insurance policy or plan based on a retrospective review of the medical necessity and appropriateness of the allocation of health care resources and services, the payor shall afford the health care providers the opportunity to appeal the determination in the same manner afforded the enrollee, with the enrollee's consent to act on his or her behalf, but in no event shall health care providers be precluded from appeal if the enrollee is not reasonably available or competent to consent. Such appeal shall not be construed to imply or confer on such health care providers any contract rights with respect to the enrollee's health insurance policy or plan that the health care provider does not otherwise have.

Revisor's Note

Section 11(b), V.T.I.C. Article 21.58A, refers to a "health insurance policy or plan." The revised law substitutes a reference to a "health insurance policy or health benefit plan" for the reason stated in Revisor's Note (7) to Section 4201.002.

[Sections 4201.503-4201.550 reserved for expansion]

SUBCHAPTER L. CONFIDENTIALITY OF INFORMATION; ACCESS TO OTHER INFORMATION

Revised Law

Sec. 4201.551. GENERAL CONFIDENTIALITY REQUIREMENT. (a) A utilization review agent shall preserve the confidentiality of individual medical records to the extent required by law.

(b) This chapter does not authorize a utilization review agent to take any action that violates a state or federal law or regulation concerning confidentiality of patient records. (V.T.I.C. Art. 21.58A, Secs. 8(a), (h) (part).)

Source Law

Sec. 8. (a) A utilization review agent shall preserve the confidentiality of individual medical records to the extent required by law.

(h) … Nothing in this article shall be construed to allow a utilization review agent to take actions that violate a state or federal statute or regulation concerning confidentiality of patient records.

Revised Law

Sec. 4201.552. CONSENT REQUIREMENTS. (a) A utilization review agent may not disclose individual medical records, personal information, or other confidential information about a patient obtained in the performance of utilization review without the patient's prior written consent or except as otherwise required by law.

(b) If the prior written consent is submitted by anyone other than the patient who is the subject of the personal or confidential information requested, the consent must:

(1) be dated; and

(2) contain the patient's signature.

(c) The patient's signature for purposes of Subsection (b)(2) must have been obtained one year or less before the date the disclosure is sought or the consent is invalid. (V.T.I.C. Art. 21.58A, Sec. 8(b).)

Source Law

(b) A utilization review agent may not disclose or publish individual medical records, personal information, or other confidential information about a patient obtained in the performance of utilization review without the prior written consent of the patient or as otherwise required by law. If such authorization is submitted by anyone other than the individual who is the subject of the personal or confidential information requested, such authorization must:

(1) be dated; and

(2) contain the signature of the individual who is the subject of the personal or confidential information requested. The signature must have been obtained one year or less prior to the date the disclosure is sought or the authorization is invalid.

Revisor's Note

Section 8(b), V.T.I.C. Article 21.58A, provides that a utilization review agent may not "disclose or publish" certain information. The revised law omits the reference to "publish" because, in this context, "publish" is included in the meaning of "disclose."

Revised Law

Sec. 4201.553. PROVIDING INFORMATION TO AFFILIATED ENTITIES. A utilization review agent may provide confidential information to a third party under contract with or affiliated with the agent solely to perform or assist with utilization review. Information provided to a third party under this section remains confidential. (V.T.I.C. Art. 21.58A, Sec. 8(c).)

Source Law

(c) A utilization review agent may provide confidential information to a third party under contract or affiliated with the utilization review agent for the sole purpose of performing or assisting with utilization review. Information provided to third parties shall remain confidential.

Revised Law

Sec. 4201.554. PROVIDING INFORMATION TO COMMISSIONER. Notwithstanding this subchapter, a utilization review agent shall provide to the commissioner on request individual medical records or other confidential information to enable the commissioner to determine compliance with this chapter. The information is confidential and privileged and is not subject to Chapter 552, Government Code, or to subpoena, except to the extent necessary to enable the commissioner to enforce this chapter. (V.T.I.C. Art. 21.58A, Sec. 8(i).)

Source Law

(i) Notwithstanding the provisions in Subsections (a) through (h) of this section, the utilization review agent shall provide to the commissioner on request individual medical records or other confidential information for determination of compliance with this article. The information is confidential and privileged and is not subject to the open records law, Chapter 552, Government Code, or to subpoena, except to the extent necessary to enable the commissioner to enforce this article.

Revisor's Note

Section 8(i), V.T.I.C. Article 21.58A, provides that, "[n]otwithstanding the provisions in Subsections (a) through (h)" of Section 8, a utilization review agent shall provide certain confidential information to the commissioner of insurance. The referenced provisions are revised as Subchapter L of this chapter, which includes this section, with the exception of Section 8(f), as added by Chapter 163, Acts of the 75th Legislature, Regular Session, 1997. That section is revised in Subchapter I of this chapter as Section 4201.402(b). The revised law substitutes "[n]otwithstanding this subchapter" for the quoted language and does not include a reference to Section 4201.402(b) because that provision does not restrict or otherwise relate to a utilization review agent providing information to the commissioner.

Revised Law

Sec. 4201.555. ACCESS TO RECORDED PERSONAL INFORMATION. (a) If an individual submits a written request to a utilization review agent for access to recorded personal information concerning the individual, the agent shall, within 10 business days from the date the agent receives the request:

(1) inform the requesting individual in writing of the nature and substance of the recorded personal information; and

(2) allow the individual, at the individual's discretion, to:

(A) view and copy, in person, the recorded personal information concerning the individual; or

(B) obtain a copy of the information by mail.

(b) If the information requested under this section is in coded form, the utilization review agent shall provide in writing an accurate translation of the information in plain language.

(c) A utilization review agent's charges for providing a copy of information requested under this section shall be reasonable, as determined by rule adopted by the commissioner. The charges may not include any costs otherwise recouped as part of the charges for utilization review. (V.T.I.C. Art. 21.58A, Secs. 8(d), (e).)

Source Law

(d) If an individual submits a written request to the utilization review agent for access to recorded personal information about the individual, the utilization review agent shall within 10 business days from the date such request is received:

(1) inform the individual submitting the request of the nature and substance of the recorded personal information in writing; and

(2) permit the individual to see and copy, in person, the recorded personal information pertaining to the individual or to obtain a copy of the recorded personal information by mail, at the discretion of the individual, unless the recorded personal information is in coded form, in which case an accurate translation in plain language shall be provided in writing.

(e) A utilization review agent's charges for providing a copy of recorded personal information to individuals shall be reasonable, as determined by rule of the commissioner, and may not include any costs that are otherwise recouped as part of the charge for utilization review.

Revised Law

Sec. 4201.556. PUBLISHING INFORMATION IDENTIFIABLE TO HEALTH CARE PROVIDER. (a) A utilization review agent may not publish data that identifies a particular physician or other health care provider, including data in a quality review study or performance tracking data, without providing prior written notice to the physician or other provider.

(b) The prohibition under this section does not apply to internal systems or reports used by the utilization review agent. (V.T.I.C. Art. 21.58A, Sec. 8(f), as added Acts 75th Leg., R.S., Ch. 1025.)

Source Law

(f) The utilization review agent may not publish data which identifies a particular physician or health care provider, including any quality review studies or performance tracking data, without prior written notice to the involved provider. This prohibition does not apply to internal systems or reports used by the utilization review agent.

Revised Law

Sec. 4201.557. REQUIREMENT TO MAINTAIN DATA IN CONFIDENTIAL MANNER. A utilization review agent shall maintain all data concerning a patient or physician or other health care provider in a confidential manner that prevents unauthorized disclosure to a third party. (V.T.I.C. Art. 21.58A, Sec. 8(h) (part).)

Source Law

(h) All patient, physician, and health care provider data shall be maintained by the utilization review agent in a confidential manner which prevents unauthorized disclosure to third parties. …

Revised Law

Sec. 4201.558. DESTRUCTION OF CERTAIN CONFIDENTIAL DOCUMENTS. When a utilization review agent determines a document in the custody of the agent that contains confidential patient information or confidential physician or other health care provider financial data is no longer needed, the document shall be destroyed by a method that ensures the complete destruction of the information. (V.T.I.C. Art. 21.58A, Sec. 8(g).)

Source Law

(g) Documents in the custody of the utilization review agent that contain confidential patient information or physician or health care provider financial data shall be destroyed by a method which induces complete destruction of the information when the agent determines the information is no longer needed.

[Sections 4201.559-4201.600 reserved for expansion]

SUBCHAPTER M. ENFORCEMENT

Revised Law

Sec. 4201.601. NOTICE OF SUSPECTED VIOLATION; COMPELLING PRODUCTION OF INFORMATION. If the commissioner believes that a person or entity conducting utilization review is in violation of this chapter or applicable rules, the commissioner:

(1) shall notify the utilization review agent, health maintenance organization, or insurer of the alleged violation; and

(2) may compel the production of documents or other information as necessary to determine whether a violation has occurred. (V.T.I.C. Art. 21.58A, Sec. 9(a).)

Source Law

Sec. 9. (a) If the commissioner believes that any person or entity conducting utilization review pursuant to this article is in violation of this article or applicable regulations, the commissioner shall notify the utilization review agent, health maintenance organization, or insurer of the alleged violation and may compel the production of any and all documents or other information as necessary in order to determine whether or not such violation has taken place.

Revisor's Note

Section 9(a), V.T.I.C. Article 21.58A, refers to "regulations" concerning utilization review. The revised law substitutes "rules" for "regulations" for the reason stated in Revisor's Note (3) to Section 4201.003.

Revised Law

Sec. 4201.602. ENFORCEMENT PROCEEDING. (a) The commissioner may initiate a proceeding under this subchapter.

(b) A proceeding under this chapter is a contested case for purposes of Chapter 2001, Government Code. (V.T.I.C. Art. 21.58A, Secs. 9(b), (c).)

Source Law

(b) The commissioner may initiate the proceedings under this section.

Revised Law

Sec. 4201.603. REMEDIES AND PENALTIES FOR VIOLATION. If the commissioner determines that a utilization review agent, health maintenance organization, insurer, or other person or entity conducting utilization review has violated or is violating this chapter, the commissioner may:

(1) impose a sanction under Chapter 82;

(2) issue a cease and desist order under Chapter 83; or

(3) assess an administrative penalty under Chapter 84. (V.T.I.C. Art. 21.58A, Sec. 9(d).)

Source Law

(d) If the commissioner determines that the utilization review agent, health maintenance organization, insurer, or other person or entity conducting utilization review pursuant to this article has violated or is violating any provision of this article, the commissioner may:

(1) impose sanctions under Section 7, Article 1.10 of this code;

(2) issue a cease and desist order under Article 1.10A of this code; or

(3) assess administrative penalties under Article 1.10E of this code.


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