Tex. Ins. Code Section 4201.359
Notice of Appeal


(a)

The procedures for appealing an adverse determination must require written notice to the appealing party of the determination of the appeal as soon as practicable, but not later than the 30th calendar day, after the date the utilization review agent receives the appeal.

(b)

If the appeal is denied, the notice must include a clear and concise statement of:

(1)

the clinical basis for the denial;

(2)

the specialty of the physician or other health care provider making the denial; and

(3)

the appealing party’s right to seek review of the denial by an independent review organization under Subchapter I and the procedures for obtaining that review.
Added by Acts 2005, 79th Leg., Ch. 727 (H.B. 2017), Sec. 4, eff. April 1, 2007.

Source: Section 4201.359 — Notice of Appeal, https://statutes.­capitol.­texas.­gov/Docs/IN/htm/IN.­4201.­htm#4201.­359 (accessed Nov. 25, 2023).

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

Accessed:
Nov. 25, 2023

§ 4201.359’s source at texas​.gov