Tex. 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.
Added by Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 4.02, eff. September 1, 2005.
Amended by:
Acts 2007, 80th Leg., R.S., Ch. 134 (H.B. 1006), Sec. 6, eff. September 1, 2007.
Acts 2007, 80th Leg., R.S., Ch. 730 (H.B. 2636), Sec. 2G.010, eff. April 1, 2009.
Acts 2009, 81st Leg., R.S., Ch. 1330 (H.B. 4290), Sec. 5, eff. September 1, 2009.
Acts 2019, 86th Leg., R.S., Ch. 1218 (S.B. 1742), Sec. 3.11, eff. September 1, 2019.

Source: Section 1305.351 — Utilization Review in Network, https://statutes.­capitol.­texas.­gov/Docs/IN/htm/IN.­1305.­htm#1305.­351 (accessed May 4, 2024).

1305.001
Short Title
1305.002
Purpose
1305.003
Limitations on Applicability
1305.004
Definitions
1305.005
Participation in Network
1305.006
Insurance Carrier Liability for Out-of-network Health Care
1305.007
Rules
1305.008
Administrator Certificate of Authority Required
1305.051
Certification Required
1305.052
Certificate Application
1305.053
Contents of Application
1305.054
Action on Application
1305.055
Use of Certain Insurance Terms by Network Prohibited
1305.056
Restraint of Trade
1305.101
Providing or Arranging for Health Care
1305.102
Management Contracts
1305.103
Treating Doctor
1305.104
Selection of Treating Doctor
1305.106
Payment of Health Care Provider
1305.107
Telephone Access
1305.151
Transfer of Risk
1305.152
Network Contracts with Providers
1305.153
Provider Reimbursement
1305.154
Network-carrier Contracts
1305.155
Compliance Requirements
1305.201
Network Financial Requirements
1305.251
Examination of Network
1305.252
Examination of Provider or Third Party
1305.301
Network Organization
1305.302
Accessibility and Availability Requirements
1305.303
Quality of Care Requirements
1305.304
Guidelines and Protocols
1305.351
Utilization Review in Network
1305.353
Notice of Certain Utilization Review Determinations
1305.354
Reconsideration of Adverse Determination
1305.355
Independent Review of Adverse Determination
1305.356
Contested Case Hearing on and Judicial Review of Independent Review
1305.401
Complaint System Required
1305.402
Complaint Initiation and Initial Response
1305.403
Record of Complaints
1305.404
Retaliatory Action Prohibited
1305.405
Posting of Information on Complaint Process Required
1305.451
Employee Information
1305.502
Consumer Report Cards
1305.503
Confidentiality Requirements
1305.551
Determination of Violation
1305.552
Disciplinary Actions
1305.1545
Restrictions on Payment and Reimbursement

Accessed:
May 4, 2024

§ 1305.351’s source at texas​.gov