Section 413.002 requires the division to monitor health care providers, insurance carriers, independent review organizations, and workers' compensation claimants who receive medical services to ensure compliance with division rules relating to health care, including medical policies and fee guidelines. Section 413.011 requires the commissioner to adopt health care reimbursement policies and guidelines. Section 413.0111 requires that rules adopted by the commissioner for the reimbursement of prescription medications and services must authorize pharmacies to use agents or assignees to process claims and act on the behalf of the pharmacies under terms and conditions agreed on by the pharmacies. Section 413.013(1), (2) and (3) require the division by rule to establish a program for prospective, concurrent, and retrospective review and resolution of a dispute regarding health care treatments and services, a program for the systematic monitoring of the necessity of the treatments administered and fees charged and paid for medical treatments or services including the authorization of prospective, concurrent or retrospective review under the medical policies of the division to ensure the medical policies and guidelines are not exceeded, and a program to detect practices and patterns by insurance carriers in unreasonably denying authorization of payment for medical services requested or performed if authorization is required by the medical policies of the division. Section 413.017 establishes a presumption of reasonableness of medical services consistent with the medical policies and fee guidelines adopted by the division and medical services that are provided subject to prospective, concurrent, or retrospective review and required by the medical policies of the division and that are authorized by an insurance carrier. Section 413.031 entitles a party, including a health care provider, to a review of a medical service provided or for which authorization of payment is sought if a health care provider has been denied payment, paid a reduced amount for the medical service rendered, or denied authorization for the payment for the service required or performed if authorization is required or allowed by Labor Code Title 5 or division rules.

Insurance Code §4201.054 provides that Chapter 4201 applies to utilization review of a health care service provided to a person eligible for workers' compensation medical benefits under Title 5, Labor Code; the commissioner of workers' compensation shall regulate as provided by Chapter 4201 a person who performs utilization review of a medical benefit provided under Title 5, Labor Code; Title 5, Labor Code, prevails in the event of a conflict between Chapter 4201 and Title 5, Labor Code; and the commissioner of workers' compensation may adopt rules as necessary to implement §4201.054.