2022 Texas Statutes
Insurance Code
Title 14 - Utilization Review and Independent Review
Chapter 4201 - Utilization Review Agents
Subchapter E. Utilization Review: Relations With Patients and Health Care Providers
Section 4201.206. Opportunity to Discuss Treatment Before Adverse Determination

Universal Citation: TX Ins Code § 4201.206 (2022)

Sec. 4201.206. OPPORTUNITY TO DISCUSS TREATMENT BEFORE ADVERSE DETERMINATION. (a) Subject to Subsection (b) and the notice requirements of Subchapter G, before an adverse determination is issued by a utilization review agent who questions the medical necessity, the appropriateness, or the experimental or investigational nature of a health care service, the agent shall provide the health care provider who ordered, requested, provided, or is to provide the service a reasonable opportunity to discuss with a physician licensed to practice medicine in this state the patient's treatment plan and the clinical basis for the agent's determination.

(b) If the health care service described by Subsection (a) was ordered, requested, or provided, or is to be provided by a physician, the opportunity described by that subsection must be with a physician licensed to practice medicine in this state and who has the same or similar specialty as the physician.

Added by Acts 2005, 79th Leg., Ch. 727 (H.B. 2017), Sec. 4, eff. April 1, 2007.

Amended by:

Acts 2009, 81st Leg., R.S., Ch. 1330 (H.B. 4290), Sec. 9, eff. September 1, 2009.

Acts 2019, 86th Leg., R.S., Ch. 1218 (S.B. 1742), Sec. 3.03, eff. September 1, 2019.

Acts 2021, 87th Leg., R.S., Ch. 1018 (H.B. 3459), Sec. 4, eff. September 1, 2021.

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