| (a) Limitations on applicability. Except as provided
in Insurance Code Chapter 4201, this subchapter applies to utilization
review performed under a health benefit plan or a health insurance
policy.
(1) This subchapter does not apply to utilization review
performed under workers' compensation insurance coverage.
(2) This subchapter does not apply to a person who
provides information to an enrollee; an individual acting on behalf
of an enrollee; or an enrollee's physician, doctor, or other health
care provider about scope of coverage or benefits, and does not determine
the medical necessity, appropriateness, or the experimental or investigational
nature of health care services.
(b) Applicability of other law. In addition to the
requirements of this subchapter, provisions of Insurance Code Chapter
843, concerning Health Maintenance Organizations; Insurance Code Chapter
1222, concerning Preauthorization for Medical or Health Care Service;
Insurance Code Chapter 1301, concerning Preferred Provider Benefit
Plans; Insurance Code Chapter 1352, concerning Brain Injury; Insurance
Code Chapter 1369, concerning Benefits Related to Prescription Drugs
and Devices and Related Services; and Insurance Code Chapter 1451,
Subchapter E, concerning Dental Care Benefits in Health Insurance
Policies or Employee Benefit Plans, apply to this subchapter.
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