Texas Administrative Code
|PART 1||TEXAS DEPARTMENT OF INSURANCE|
|CHAPTER 19||LICENSING AND REGULATION OF INSURANCE PROFESSIONALS|
|SUBCHAPTER R||UTILIZATION REVIEWS FOR HEALTH CARE PROVIDED UNDER A HEALTH BENEFIT PLAN OR HEALTH INSURANCE POLICY|
|RULE §19.1710||Requirements Prior to Issuing Adverse Determination|
In any instance in which the URA is questioning the medical necessity or 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. 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.
|Source Note: The provisions of this §19.1710 adopted to be effective February 20, 2013, 38 TexReg 892|