Ins. Code Section 1305.351
Utilization Review in Network
(a)The requirements of Chapter 4201 (Utilization Review Agents) apply to utilization review conducted in relation to claims in a workers’ compensation health care network. In the event of a conflict between Chapter 4201 (Utilization Review Agents) and this chapter, this chapter controls.
(b)Any screening criteria used for utilization review related to a workers’ compensation health care network must be consistent with the network’s treatment guidelines.
(c)The preauthorization requirements of Section 413.014 (Preauthorization Requirements; Concurrent Review and Certification of Health Care), Labor Code, and commissioner of workers’ compensation rules adopted under that section, do not apply to health care provided through a workers’ compensation network. If a network or carrier uses a preauthorization process within a network, the requirements of this subchapter and commissioner rules apply. A network or an insurance carrier may not require preauthorization of treatments and services for a medical emergency.
(d)A utilization review agent or an insurance carrier that uses doctors to perform reviews of health care services provided under this chapter, including utilization review, or peer reviews under Section 408.0231 (Maintenance of List of Approved Doctors; Sanctions and Privileges Relating to Health Care)(g), Labor Code, may only use doctors licensed to practice in this state.
Section 1305.351 — Utilization Review in Network,
https://statutes.capitol.texas.gov/Docs/IN/htm/IN.1305.htm#1305.351 (accessed Dec. 2, 2023).