Tex.
Ins. Code Section 4201.656
Independent Review of Exemption Determination
(a)
A physician or provider has a right to a review of an adverse determination regarding a preauthorization exemption be conducted by an independent review organization. A health maintenance organization or insurer may not require a physician or provider to engage in an internal appeal process before requesting a review by an independent review organization under this section.(b)
A health maintenance organization or insurer shall pay:(1)
for any appeal or independent review of an adverse determination regarding a preauthorization exemption requested under this section; and(2)
a reasonable fee determined by the Texas Medical Board for any copies of medical records or other documents requested from a physician or provider during an exemption rescission review requested under this section.(c)
An independent review organization must complete an expedited review of an adverse determination regarding a preauthorization exemption not later than the 30th day after the date a physician or provider files the request for a review under this section.(d)
A physician or provider may request that the independent review organization consider another random sample of not less than five and no more than 20 claims submitted to the health maintenance organization or insurer by the physician or provider during the relevant evaluation period for the relevant health care service as part of its review. If the physician or provider makes a request under this subsection, the independent review organization shall base its determination on the medical necessity of claims reviewed by the health maintenance organization or insurer under Section 4201.655 (Denial or Rescission of Preauthorization Exemption) and reviewed under this subsection.
Source:
Section 4201.656 — Independent Review of Exemption Determination, https://statutes.capitol.texas.gov/Docs/IN/htm/IN.4201.htm#4201.656 (accessed Jun. 5, 2024).
