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Texas Laws | Insurance Code
INSURANCE CODE
TITLE 14. UTILIZATION REVIEW AND INDEPENDENT REVIEW

If the commissioner believes that a person or entity conducting utilization review is in violation of this chapter or applicable rules, the commissioner: (55360)

(1) shall notify the utilization review agent, health maintenance organization, or insurer of the alleged violation; and (55361)

(2) may compel the production of documents or other information as necessary to determine whether a violation has occurred. (55362)

Added by Acts 2005, 79th Leg., Ch. 727 (H.B. 2017), Sec. 4, eff. April 1, 2007. (55363)

Sec. 4201.602. ENFORCEMENT PROCEEDING. (55364)(Text)

(a) The commissioner may initiate a proceeding under this subchapter. (55365)

(b) A proceeding under this chapter is a contested case for purposes of Chapter 2001, Government Code. (55366)

Added by Acts 2005, 79th Leg., Ch. 727 (H.B. 2017), Sec. 4, eff. April 1, 2007. (55367)

Sec. 4201.603. REMEDIES AND PENALTIES FOR VIOLATION. (55368)(Text)

If the commissioner determines that a utilization review agent, health maintenance organization, insurer, or other person or entity conducting utilization review has violated or is violating this chapter, the commissioner may: (55369)

(1) impose a sanction under Chapter 82; (55370)

(2) issue a cease and desist order under Chapter 83; or (55371)

(3) assess an administrative penalty under Chapter 84. (55372)

Added by Acts 2005, 79th Leg., Ch. 727 (H.B. 2017), Sec. 4, eff. April 1, 2007. (55373)

CHAPTER 4202. INDEPENDENT REVIEW ORGANIZATIONS (55374)(Text)

Sec. 4202.001. DEFINITION. (55375)(Text)

In this chapter, "payor" has the meaning assigned by Section 4201.002. (55376)

Added by Acts 2005, 79th Leg., Ch. 727 (H.B. 2017), Sec. 4, eff. April 1, 2007. (55377)

Sec. 4202.002. ADOPTION OF STANDARDS FOR INDEPENDENT REVIEW ORGANIZATIONS. (55378)(Text)

(a) The commissioner shall adopt standards and rules for: (55379)

(1) the certification, selection, and operation of independent review organizations to perform independent review described by Subchapter I, Chapter 4201; and (55380)

(2) the suspension and revocation of the certification. (55381)

(b) The standards adopted under this section must ensure: (55382)

(1) the timely response of an independent review organization selected under this chapter; (55383)

(2) the confidentiality of medical records transmitted to an independent review organization for use in conducting an independent review; (55384)

(3) the qualifications and independence of each physician or other health care provider making a review determination for an independent review organization; (55385)

(4) the fairness of the procedures used by an independent review organization in making review determinations; and (55386)

(5) the timely notice to an enrollee of the results of an independent review, including the clinical basis for the review determination. (55387)

(c) In addition to the standards described by Subsection (b), the commissioner shall adopt standards and rules that: (55388)

(1) prohibit: (55389)

(A) more than one independent review organization from operating out of the same office or other facility; (55390)

(B) an individual or entity from owning more than one independent review organization; (55391)

(C) an individual from owning stock in or serving on the board of more than one independent review organization; (55392)

(D) an individual who has served on the board of an independent review organization whose certification was revoked for cause from serving on the board of another independent review organization before the fifth anniversary of the date on which the revocation occurred; (55393)

(E) an individual who serves as an officer, director, manager, executive, or supervisor of an independent review organization from serving as an officer, director, manager, executive, supervisor, employee, agent, or independent contractor of another independent review organization; and (55394)

(F) an independent review organization from: (55395)

(i) publicly disclosing patient information protected by the Health Insurance Portability and Accountability Act of 1996 (42 U.S.C. Section 1320d et seq.); or (55396)

(ii) transmitting the information to a subcontractor involved in the independent review process that has not signed an agreement similar to the business associate agreement required by regulations adopted under the Health Insurance Portability and Accountability Act of 1996 (42 U.S.C. Section 1320d et seq.); and (55397)

(2) require: (55398)

(A) an independent review organization to: (55399)

(i) maintain a physical address and a mailing address in this state; (55400)

(ii) be incorporated in this state; (55401)

(iii) be in good standing with the comptroller; and (55402)

(iv) be based and certified in this state and to locate the organization's primary offices in this state; (55403)

(B) an independent review organization to surrender the organization's certification as part of an agreed order; and (55404)

(C) an independent review organization to: (55405)

(i) notify the department of an agreement to sell the organization or shares in the organization; (55406)

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