Tex.
Ins. Code Section 843.261
Special Provisions for Appeals of Adverse Determinations
(a)
A health maintenance organization shall implement and maintain an internal appeal system that:(1)
provides reasonable procedures for the resolution of an oral or written appeal concerning dissatisfaction or disagreement with an adverse determination; and(2)
includes procedures for notification, review, and appeal of an adverse determination in accordance with Chapter 4201 (Utilization Review Agents).(b)
An appeal must be initiated by an enrollee, a person acting on behalf of an enrollee, or an enrollee’s provider of record.(c)
When an enrollee, a person acting on behalf of an enrollee, or an enrollee’s provider of record expresses orally or in writing any dissatisfaction or disagreement with an adverse determination, the health maintenance organization or utilization review agent shall:(1)
consider the expression of dissatisfaction or disagreement as an appeal of the adverse determination; and(2)
review and resolve the appeal in accordance with Chapter 4201 (Utilization Review Agents).(d)
A health maintenance organization may integrate its appeal procedures related to adverse determinations with the complaint and appeal procedures established by the health maintenance organization under Section 843.251 (Complaint System Required; Commissioner Rules and Examination) and otherwise governed by this subchapter only if the procedures related to adverse determinations comply with this section and Chapter 4201 (Utilization Review Agents).
Source:
Section 843.261 — Special Provisions for Appeals of Adverse Determinations, https://statutes.capitol.texas.gov/Docs/IN/htm/IN.843.htm#843.261 (accessed May 26, 2025).
