| (a) Limitations on applicability. Except as provided
in Insurance Code Chapter 4201, this subchapter applies to utilization
review performed under workers' compensation insurance coverage. This
subchapter does not affect the authority of TDI-DWC to exercise the
powers granted to it under Labor Code Title 5 and Insurance Code Chapter
4201. This subchapter applies to utilization review as set forth in
Insurance Code Chapters 1305 and 4201 and Labor Code Title 5.
(1) This subchapter does not apply to utilization review
performed under a health benefit plan or a health insurance policy.
(2) This subchapter does not apply to a person who
provides information to an injured employee or an injured employee's
representative, physician, doctor, or other health care provider about
scope of coverage or benefits provided for under workers' compensation
insurance coverage, and does not determine medical necessity or appropriateness
or the experimental or investigational nature of health care services.
(b) Applicability of other law.
(1) Health care providers performing peer reviews regarding
the prospective, concurrent, or retrospective review of the medical
necessity or appropriateness of health care are performing utilization
review, must generate a written report, and must comply with this
subchapter, Labor Code Title 5, and rules adopted under the Texas
Workers' Compensation Act including, but not limited to, Chapter 180
of this title (relating to Monitoring and Enforcement).
(2) Insurance carriers must process medical bills as
required by Labor Code Title 5 and rules adopted under the Texas Workers'
Compensation Act including, but not limited to, Chapter 133, Subchapter
A, of this title (relating to General Rules for Medical Billing and
Processing).
(3) If there is a conflict between this subchapter
and rules adopted by the commissioner of workers' compensation, the
rules adopted by the commissioner of workers' compensation prevail.
(4) If there is a conflict between this subchapter
and the rules in Chapter 10 of this title, regarding Workers' Compensation
Health Care Networks, the rules in Chapter 10 of this title prevail.
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