| (a) Applicability of certification or registration
requirements. A person acting as or holding itself out as a URA under
this subchapter must be certified or registered, as applicable, under
Insurance Code §4201.057, concerning Health Maintenance Organizations;
Insurance Code §4201.058, concerning Insurers; or Insurance Code §4201.101,
concerning Certificate of Registration Required, and this subchapter.
(1) If an insurance carrier or HMO performs utilization
review for an individual or entity subject to this subchapter for
which it is not the payor, the insurance carrier or HMO must be certified.
(2) If an insurance carrier or HMO performs utilization
review only for coverage for which it is the payor, the insurance
carrier or HMO must be registered.
(b) Application form. The commissioner adopts by reference
the:
(1) URA application, for application for, renewal of,
and reporting a material change to a certification or registration
as a URA in this state; and
(2) Biographical affidavit, to be used as an attachment
to the URA application.
(c) Original application fee. The original application
fee specified in §19.802 of this title (relating to Amount of
Fees) must be sent to TDI with the application for certification.
A person applying for registration is not required to pay a fee.
(d) Where to obtain and send the URA application form.
Forms may be obtained from www.tdi.texas.gov/forms and must be sent
to: Texas Department of Insurance, Managed Care Quality Assurance
Office, MC: LH-MCQA, P.O. Box 12030, Austin, Texas 78711-2030.
(e) Original application process. Within 60 calendar
days after receipt of a complete application, TDI will process the
application and issue or deny a certification or registration. TDI
will send a certificate or a letter of registration to an entity that
is granted certification or registration. The applicant may waive
the time limit described in this subsection.
(f) Omissions or deficiencies. TDI will send the applicant
written notice of any omissions or deficiencies in the application.
The applicant must correct the omissions or deficiencies in the application
or request additional time in writing within 15 working days of the
date of TDI's latest notice of the omissions or deficiencies. If the
applicant fails to do so, the application will not be processed and
the file will be closed as an incomplete application. The application
fee is not refundable. The request for additional time must be approved
by TDI in writing to be effective.
(g) Certification and registration expiration. Each
URA registration or certification issued by TDI and not suspended
or revoked by the commissioner expires on the second anniversary of
the date of issuance.
(h) Renewal requirements. A URA must apply for renewal
of certification or registration every two years from the date of
issuance by submitting the URA application form to TDI. The URA must
also submit a renewal fee in the amount specified by §19.802(b)(19)
of this title for renewal of a certification. A person applying for
renewal of a registration is not required to pay a fee.
(1) Continued operation during review. If a URA submits
the required information and fees specified in this subsection on
or before the expiration of the certification or registration, the
URA may continue to operate under its certification or registration
until the renewal certification or registration is denied or issued.
(2) Expiration for 90 calendar days or less. If the
certification or registration has been expired for 90 calendar days
or less, a URA may renew the certification or registration by sending
a completed renewal application and fee, as applicable. The URA may
not operate from the time the certification or registration has expired
until the time TDI has issued a renewal certification or registration.
(3) Expiration for longer than 90 calendar days. If
a URA's certification or registration has been expired for longer
than 90 calendar days, the URA may not renew the certification or
registration. The URA must obtain a new certification or registration
by submitting an application for original issuance of the certification
or registration and an original application fee as applicable.
(i) Contesting a denial. If an application for an original
or renewal certification or registration is denied, the applicant
may contest the denial under the provisions of Chapter 1, Subchapter
A, of this title (relating to Rules of Practice and Procedure) and
Government Code Chapter 2001, concerning Administrative Procedure.
(j) Updating information on effective date. A URA that
is certified or registered before the effective date of this rule
must submit an updated application to TDI to comply with this subchapter
within 90 calendar days after the effective date of this rule. However,
the submission of an updated application does not change the URA's
existing renewal date, and this section still governs the URA's renewal
process.
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