CHAPTER 4202.  INDEPENDENT REVIEW ORGANIZATIONS

Revised Law

Sec. 4202.001.  DEFINITION.  In this chapter, "payor" has the meaning assigned by Section ___ [[[Sec. 2, Art. 21.58A]]].  (V.T.I.C. Art. 21.58C, Sec. 1(2).)

Source Law

     (2)  "Payor" has the meaning assigned by Section 2, Article 21.58A of this code.

Revised Law

Sec. 4202.002.  ADOPTION OF STANDARDS FOR INDEPENDENT REVIEW ORGANIZATIONS.  (a)  The commissioner shall adopt standards and rules for:

     (1)  the certification, selection, and operation of organizations to perform independent review described by Section ___ [[[Sec. 6A, Art. 21.58A]]]; and

     (2)  the suspension and revocation of the certification.

(b)  The standards adopted under this section must ensure:

     (1)  the timely response of an independent review organization selected under this chapter;

     (2)  the confidentiality of medical records transmitted to an independent review organization for use in conducting an independent review;

     (3)  the qualifications and independence of each physician or other health care provider making a review determination for an independent review organization;

     (4)  the fairness of the procedures used by an independent review organization in making review determinations; and

     (5)  the timely notice to an enrollee of the results of an independent review, including the clinical basis for the review determination.  (V.T.I.C. Art. 21.58C, Secs. 2(a) (part), (b).)

Source Law

Sec. 2.  (a)  The commissioner shall:

     (1)  promulgate standards and rules for:

          (A)  the certification, selection, and operation of independent review organizations to perform independent review described by Section 6, Article 21.58A of this code; and

          (B)  the suspension and revocation of the certification;

     … .

(b)  The standards required by Subsection (a)(1) of this section must ensure:

     (1)  the timely response of an independent review organization selected under this article;

     (2)  the confidentiality of medical records transmitted to an independent review organization for use in independent reviews;

     (3)  the qualifications and independence of each health care provider or physician making review determinations for an independent review organization;

     (4)  the fairness of the procedures used by an independent review organization in making the determinations; and

     (5)  timely notice to enrollees of the results of the independent review, including the clinical basis for the determination.

Revisor's Note

Section 2(a)(1)(A), V.T.I.C. Article 21.58C, refers to independent review organizations that perform "independent review described by Section 6, Article 21.58A of this code."  The reference to Section 6, V.T.I.C. Article 21.58A, appears to be a typographical error.  Section 6, Article 21.58A, revised as Section ____ of this code, provides procedures for appealing an adverse determination made by a utilization review agent.  The review of an appeal under Section 6 is conducted by a physician or other health care provider under the direction of the utilization review agent.  If the appeal of the adverse determination is denied under Section 6, the party whose appeal was denied may appeal to an independent review organization under Section 6A, V.T.I.C. Article 21.58A, revised as Section ___ of this code.  It is clear from the context that the legislature intended to refer to independent review conducted by an independent review organization as provided by Section 6A.  For that reason, the revised law substitutes a reference to Section ___ of this code [[[Sec. 6A, Art. 21.58A]]].

Revised Law

Sec. 4202.003.  REQUIREMENTS REGARDING TIMELINESS OF DETERMINATION.  The standards adopted under Section 4202.002 must require each independent review organization to make the organization's determination:

     (1)  for a life-threatening condition as defined by Section __ [[[Sec. 2, Art. 21.58A]]], not later than the earlier of:

          (A)  the fifth day after the date the organization receives the information necessary to make the determination; or

          (B)  the eighth day after the date the organization receives the request that the determination be made; and

     (2)  for a condition other than a life-threatening condition, not later than the earlier of:

          (A)  the 15th day after the date the organization receives the information necessary to make the determination; or

          (B)  the 20th day after the date the organization receives the request that the determination be made.  (V.T.I.C. Art. 21.58C, Secs. 1(1), 2(c).)

Source Law

Art. 21.58C

Sec. 1.  In this article:

     (1)  "Life-threatening condition" has the meaning assigned by Section 6, Article 21.58A of this code.

[Sec. 2]

(c)  The standards adopted under Subsection (a)(1) of this section must include standards that require each independent review organization to make its determination:

     (1)  not later than the earlier of:

          (A)  the 15th day after the date the independent review organization receives the information necessary to make the determination; or

          (B)  the 20th day after the date the independent review organization receives the request that the determination be made; and

     (2)  in the case of a life-threatening condition, not later than the earlier of:

          (A)  the fifth day after the date the independent review organization receives the information necessary to make the determination; or

          (B)  the eighth day after the date the independent review organization receives the request that the determination be made.

Revisor's Note

Section 1(1), V.T.I.C. Article 21.58C, defines "life-threatening condition" to have the meaning assigned by Section 6, V.T.I.C. Article 21.58A.  Section 6(c) of that article, as originally enacted by Chapter 163, Acts of the 75th Legislature, Regular Session, 1997, defined "life-threatening condition" for purposes of Section 6.  During the same legislative session, the legislature enacted Chapter 1025, Acts of the 75th Legislature, Regular Session, 1997, which added a definition of "life threatening" as Section 2(12), V.T.I.C. Article 21.58A, revised as Section ___ of this code.  That definition was substantively identical to the definition enacted in Section 6(c) and applied to the entire article, making the definition in Section 6(c) superfluous.  The legislature subsequently enacted Chapter 1456, Acts of the 76th Legislature, Regular Session, 1999, which repealed the definition contained in Section 6(c).  For that reason, the revised law substitutes a reference to Section ___ of this code [[[Sec. 2(12), Art. 21.58A]]] for the reference to Section 6, Article 21.58A.

In addition, the definition of "life-threatening condition" provided by Section 1(1), Article 21.58C, applies to the entire article, revised as this chapter.  The revised law incorporates the substance of the definition in this section because the term only appears in Section 2(c), Article 21.58C, which is revised in this section.

Revised Law

Sec. 4202.004.  CERTIFICATION.  To be certified as an independent review organization under this chapter, an organization must submit to the commissioner an application in the form required by the commissioner.  The application must include:

     (1)  for an applicant that is publicly held, the name of each shareholder or owner of more than five percent of any of the applicant's stock or options;

     (2)  the name of any holder of the applicant's bonds or notes that exceed $100,000;

     (3)  the name and type of business of each corporation or other organization that the applicant controls or is affiliated with and the nature and extent of the control or affiliation;

     (4)  the name and a biographical sketch of each director, officer, and executive of the applicant and of any entity listed under Subdivision (3) and a description of any relationship the named individual has with:

          (A)  a health benefit plan;

          (B)  a health maintenance organization;

          (C)  an insurer;

          (D)  a utilization review agent;

          (E)  a nonprofit health corporation;

          (F)  a payor;

          (G)  a health care provider; or

          (H)  a group representing any of the entities described by Paragraphs (A) through (G);

     (5)  the percentage of the applicant's revenues that are anticipated to be derived from independent reviews conducted under Section ___ [[[Sec. 6A, Art. 21.58A]]];

     (6)  a description of the areas of expertise of the physicians or other  health care providers making review determinations for the applicant; and

     (7)  the procedures to be used by the applicant in making review determinations under Section ___ [[[Sec. 6A, Art. 21.58A]]].  (V.T.I.C. Art. 21.58C, Sec. 2(d).)

Source Law

(d)  To be certified as an independent review organization under this article, an organization must submit to the commissioner an application in the form required by the commissioner.  The application must include:

     (1)  for an applicant that is publicly held, the name of each stockholder or owner of more than five percent of any stock or options;

     (2)  the name of any holder of bonds or notes of the applicant that exceed $100,000;

     (3)  the name and type of business of each corporation or other organization that the applicant controls or is affiliated with and the nature and extent of the affiliation or control;

     (4)  the name and a biographical sketch of each director, officer, and executive of the applicant and any entity listed under Subdivision (3) of this subsection and a description of any relationship the named individual has with:

          (A)  a health benefit plan;

          (B)  a health maintenance organization;

          (C)  an insurer;

          (D)  a utilization review agent;

          (E)  a nonprofit health corporation;

          (F)  a payor;

          (G)  a health care provider; or

          (H)  a group representing any of the entities described by Paragraphs (A) through (G) of this subdivision;

     (5)  the percentage of the applicant's revenues that are anticipated to be derived from reviews conducted under Section 6A, Article 21.58A of this code;

     (6)  a description of the areas of expertise of the health care professionals making review determinations for the applicant; and

     (7)  the procedures to be used by the independent review organization in making review determinations with respect to reviews conducted under Section 6A, Article 21.58A of this code.

Revisor's Note

Section 2(d)(6), V.T.I.C. Article 21.58C, refers to "health care professionals" who make review determinations.  The standards the commissioner of insurance is required to adopt under Section 2(b)(3), V.T.I.C. Article 21.58C, revised as Section 4202.002(b)(3), refer to a "health care provider or physician" making those determinations.  The revised law substitutes "physicians or other health care providers" for "health care professionals" for consistency of terminology throughout this chapter.

Revised Law

Sec. 4202.005.  PERIODIC REPORTING OF INFORMATION; ANNUAL DESIGNATION.  (a)  An independent review organization shall annually submit the information required in an application for certification under Section 4202.004.  Any time there is a material change in the information the organization included in the application, the organization shall submit updated information to the commissioner.

(b)  The commissioner shall designate annually each organization that meets the standards for an independent review organization adopted under Section 4202.002.  (V.T.I.C. Art. 21.58C, Secs. 2(a) (part), (e).)

Source Law

(a)  The commissioner shall:

     …

     (2)  designate annually each organization that meets the standards as an independent review organization;

     … .

(e)  The independent review organization shall annually submit the information required by Subsection (d) of this section.  If at any time there is a material change in the information included in the application under Subsection (d) of this section, the independent review organization shall submit updated information to the commissioner.

Revised Law

Sec. 4202.006.  PAYORS FEES.  The commissioner shall charge payors fees in accordance with this chapter as necessary to fund the operations of independent review organizations.  (V.T.I.C. Art. 21.58C, Sec. 2(a) (part).)

Source Law

(a)  The commissioner shall:

     …

     (3)  charge payors fees in accordance with this article as necessary to fund the operations of independent review organizations; and

     … .

Revised Law

Sec. 4202.007.  OVERSIGHT.  The commissioner shall provide ongoing oversight of the independent review organizations to ensure continued compliance with this chapter and the standards and rules adopted under this chapter.  (V.T.I.C. Art. 21.58C, Sec. 2(a) (part).)

Source Law

(a)  The commissioner shall:

     …

     (4)  provide ongoing oversight of the independent review organizations to ensure continued compliance with this article and the standards and rules adopted under this article.

Revised Law

Sec. 4202.008.  PROHIBITED OWNERSHIP OR CONTROL OF INDEPENDENT REVIEW ORGANIZATION.  An independent review organization may not be a subsidiary of, or in any way owned or controlled by, a payor or a trade or professional association of payors.  (V.T.I.C. Art. 21.58C, Sec. 2(f).)

Source Law

(f)  An independent review organization may not be a subsidiary of, or in any way owned or controlled by, a payor or a trade or professional association of payors.

Revised Law

Sec. 4202.009.  CONFIDENTIAL INFORMATION.  Information that reveals the identity of a physician or other individual health care provider who makes a review determination for an independent review organization is confidential.  (V.T.I.C. Art. 21.58C, Sec. 2(h).)

Source Law

(h)  Information that reveals the identity of a physician or individual health care provider who makes a review determination for an independent review organization is confidential.

Revised Law

Sec. 4202.010.  IMMUNITY FROM LIABILITY.  (a)  An independent review organization conducting an independent review under Section ___ [[[Sec. 6A, Art. 21.58A]]] is not liable for damages arising from the review determination made by the organization.

(b)  This section does not apply to an act or omission of the independent review organization that is made in bad faith or that involves gross negligence.  (V.T.I.C. Art. 21.58C, Sec. 2(g).)

Source Law

(g)  An independent review organization conducting a review under Section 6A, Article 21.58A of this code is not liable for damages arising from the determination made by the organization. This subsection does not apply to an act or omission of the independent review organization that is made in bad faith or that involves gross negligence.