Tex. Ins. Code Section 4201.153
Screening Criteria and Review Procedures

(a)

A utilization review agent shall use written medically acceptable screening criteria and review procedures that are established and periodically evaluated and updated with appropriate involvement from physicians, including practicing physicians, dentists, and other health care providers.

(b)

A utilization review determination shall be made in accordance with currently accepted medical or health care practices, taking into account special circumstances of the case that may require deviation from the norm stated in the screening criteria.

(c)

Screening criteria must be:

(1)

objective;

(2)

clinically valid;

(3)

compatible with established principles of health care; and

(4)

flexible enough to allow a deviation from the norm when justified on a case-by-case basis.

(d)

Screening criteria must be used to determine only whether to approve the requested treatment. A denial of requested treatment must be referred to an appropriate physician, dentist, or other health care provider to determine medical necessity.
Added by Acts 2005, 79th Leg., Ch. 727 (H.B. 2017), Sec. 4, eff. April 1, 2007.

Source: Section 4201.153 — Screening Criteria and Review Procedures, https://statutes.­capitol.­texas.­gov/Docs/IN/htm/IN.­4201.­htm#4201.­153 (accessed Jun. 5, 2024).

4201.001
Purpose 4201.002
Definitions 4201.003
Rules 4201.004
Telephone Access 4201.051
Persons Providing Information About Scope of Coverage or Benefits 4201.052
Certain Contracts with Federal Government 4201.053
Medicaid and Other State Health or Mental Health Programs 4201.054
Workers’ Compensation Benefits 4201.055
Health Care Service Provided Under Automobile Insurance Policy 4201.056
Employee Welfare Benefit Plans 4201.057
Health Maintenance Organizations 4201.058
Insurers 4201.101
Certificate of Registration Required 4201.102
Requirements for Certification 4201.103
Certificate Renewal 4201.104
Certification and Renewal Forms 4201.105
Fees 4201.106
Certificate Not Transferable 4201.107
Reporting Material Changes 4201.108
List of Utilization Review Agents 4201.151
Utilization Review Plan 4201.152
Utilization Review Under Physician 4201.153
Screening Criteria and Review Procedures 4201.154
Review and Inspection of Screening Criteria and Review Procedures 4201.155
Limitation on Notice Requirements and Review Procedures 4201.201
Repetitive Contacts with Health Care Provider or Patient 4201.202
Observing or Participating in Patient’s Care 4201.203
Mental Health Therapy 4201.204
Complaint System 4201.205
Designated Initial Contact 4201.206
Opportunity to Discuss Treatment Before Adverse Determination 4201.207
Charges by Health Care Provider for Providing Medical Information 4201.251
Delegation of Utilization Review 4201.252
Personnel 4201.253
Prohibited Bases for Employment, Compensation, Evaluations, or Performance Standards 4201.301
General Duty to Notify 4201.302
General Time for Notice 4201.303
Adverse Determination: Contents of Notice 4201.304
Time for Notice of Adverse Determination 4201.305
Notice of Adverse Determination for Retrospective Utilization Review 4201.351
Complaint as Appeal 4201.352
Written Description of Appeal Procedures 4201.353
Appeal Procedures Must Be Reasonable 4201.354
Persons or Entities Who May Appeal 4201.355
Acknowledgment of Appeal 4201.356
Decision by Physician Required 4201.357
Expedited Appeal for Denial of Emergency Care, Continued Hospitalization, Prescription Drugs or Intravenous Infusions 4201.358
Response Letter to Interested Persons 4201.359
Notice of Appeal 4201.360
Immediate Appeal to Independent Review Organization in Life-threatening Circumstances 4201.401
Review by Independent Review Organization 4201.402
Information Provided to Independent Review Organization 4201.403
Payment for Independent Review 4201.451
Definition 4201.452
Inapplicability of Certain Other Law 4201.453
Utilization Review Plan 4201.454
Utilization Review Under Direction of Provider of Same Specialty 4201.455
Personnel 4201.456
Opportunity to Discuss Treatment Before Adverse Determination 4201.457
Appeal Decisions 4201.551
General Confidentiality Requirement 4201.552
Consent Requirements 4201.553
Providing Information to Affiliated Entities 4201.554
Providing Information to Commissioner 4201.555
Access to Recorded Personal Information 4201.556
Publishing Information Identifiable to Health Care Provider 4201.557
Requirement to Maintain Data in Confidential Manner 4201.558
Destruction of Certain Confidential Documents 4201.601
Notice of Suspected Violation 4201.602
Enforcement Proceeding 4201.603
Remedies and Penalties for Violation 4201.651
Definitions 4201.652
Applicability of Subchapter 4201.653
Exemption from Preauthorization Requirements for Physicians and Providers Providing Certain Health Care Services 4201.654
Duration of Preauthorization Exemption 4201.655
Denial or Rescission of Preauthorization Exemption 4201.656
Independent Review of Exemption Determination 4201.657
Effect of Appeal or Independent Review Determination 4201.658
Eligibility for Preauthorization Exemption Following Finalized Exemption Rescission or Denial 4201.659
Effect of Preauthorization Exemption 4201.3601
Immediate Appeal to Independent Review Organization for Denial of Prescription Drugs or Intravenous Infusions
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Accessed:
Jun. 5, 2024

§ 4201.153’s source at texas​.gov