2005 Texas Insurance Code CHAPTER 4202. INDEPENDENT REVIEW ORGANIZATIONS

INSURANCE CODE

CHAPTER 4202. INDEPENDENT REVIEW ORGANIZATIONS


	§ 4202.001. DEFINITION.  In this chapter, "payor" has the 
meaning assigned by Section 4201.002.

Added by Acts 2005, 79th Leg., ch. 727, § 4, eff. April 1, 2007.           


	§ 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 
independent review organizations to perform independent review 
described by Subchapter I, Chapter 4201;  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.

Added by Acts 2005, 79th Leg., ch. 727, § 4, eff. April 1, 2007.           


	§ 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 4201.002, 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.

Added by Acts 2005, 79th Leg., ch. 727, § 4, eff. April 1, 2007.           


	§ 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 Subchapter I, Chapter 4201;
		(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 independent review determinations under Subchapter I, 
Chapter 4201.

Added by Acts 2005, 79th Leg., ch. 727, § 4, eff. April 1, 2007.           


	§ 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.  Anytime 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.

Added by Acts 2005, 79th Leg., ch. 727, § 4, eff. April 1, 2007.           


	§ 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.

Added by Acts 2005, 79th Leg., ch. 727, § 4, eff. April 1, 2007.           


	§ 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.

Added by Acts 2005, 79th Leg., ch. 727, § 4, eff. April 1, 2007.           


	§ 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.

Added by Acts 2005, 79th Leg., ch. 727, § 4, eff. April 1, 2007.           


	§ 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.

Added by Acts 2005, 79th Leg., ch. 727, § 4, eff. April 1, 2007.           


	§ 4202.010. IMMUNITY FROM LIABILITY.  (a) An independent 
review organization conducting an independent review under 
Subchapter I, Chapter 4201, 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.

Added by Acts 2005, 79th Leg., ch. 727, § 4, eff. April 1, 2007.