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 Jun. 5, 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
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Accessed:
Jun. 5, 2024

§ 1305.351’s source at texas​.gov