Texas Administrative Code
|TEXAS DEPARTMENT OF INSURANCE
|LICENSING AND REGULATION OF INSURANCE PROFESSIONALS
|UTILIZATION REVIEWS FOR HEALTH CARE PROVIDED UNDER A HEALTH BENEFIT PLAN OR HEALTH INSURANCE POLICY
|Requirements Prior to Issuing an Adverse Determination
In any instance in which the URA is questioning the medical necessity, the appropriateness, or the experimental or investigational nature of the health care services prior to the issuance of an adverse determination, the URA must afford the provider of record a reasonable opportunity to discuss the plan of treatment for the enrollee with a physician licensed to practice medicine in Texas. The discussion must include, at a minimum, the clinical basis for the URA's decision and a description of documentation or evidence, if any, that can be submitted by the provider of record that, on appeal, might lead to a different utilization review decision. If the health care service was ordered, requested, or provided, or is to be provided, by a physician, then the opportunity must be with a physician licensed to practice medicine in Texas and who has the same or similar specialty as the physician.
|Source Note: The provisions of this §19.1710 adopted to be effective February 20, 2013, 38 TexReg 892; amended to be effective March 17, 2021, 46 TexReg 1647; amended to be effective September 1, 2022, 47 TexReg 5120