In all chemical dependency treatment utilization review decisions
respecting coverage providing benefits for necessary care and treatment,
each payor and treatment provider shall use the standards and corresponding
criteria in this subchapter; on and after June 1, 1992, utilization
review decisions shall comply with all applicable requirements of
the Insurance Code, Article 21.58A. These decisions include admission
to treatment, the appropriate level of chemical dependency treatment,
continuing treatment, transferring to different levels of treatment,
or discharge from treatment. Each payor and treatment provider shall
also use this set of standards and corresponding criteria to guide
decisions concerning reasonable periods of treatment at particular
levels of treatment in a chemical dependency treatment center, as
defined in §3.8001 of this title (relating to Definitions) or
in the Insurance Code, Article 3.51-9. These standards and corresponding
criteria define the conditions under which benefits shall be provided
for the necessary care and treatment of chemical dependency. These
standards and corresponding criteria are not intended to, nor are
they in any way or manner to be construed to, establish standards
of clinical care or appropriate clinical practice. The standards and
corresponding criteria set forth in this subchapter include recommended
lengths of stay for treatment. These recommended lengths of stay are
not intended to, nor are they in any way or manner to be construed
to, establish absolute minimum or maximum periods for treatment. Initial
and continued eligibility for treatment is to be predicated on the
patient meeting the standards and corresponding criteria set forth
in this subchapter. Disputes resulting from utilization review decisions
respecting necessary care and treatment shall be settled on the basis
of the criteria in this subchapter; additionally, on and after June
1, 1992, disputes resulting from utilization review decisions respecting
necessary care and treatment shall be settled in accordance with applicable
requirements of the Insurance Code, Article 21.58A.
|
