Title IN, Insurance Code

Sec. 4153.002. EXEMPTIONS. This chapter does not apply to a person who is employed as a risk manager by: (1) a liability insurance company authorized to engage in business in this state; (2) a single employer; or (3) a public self-insurance pool. Added by Acts 2003, 78th Leg., ch…

Sec. 4153.003. RULES. The commissioner may adopt rules necessary to carry out this chapter and to regulate risk managers. Added by Acts 2003, 78th Leg., ch. 1274, Sec. 7, eff. April 1, 2005. SUBCHAPTER B. LICENSE REQUIREMENTS

Sec. 4153.051. LICENSE REQUIRED. A person may not act as or represent that the person is a risk manager in this state unless the person: (1) meets the requirements prescribed by this chapter and department rules; and (2) holds a license issued by the department. Added by Acts 200…

Sec. 4153.052. APPLICATION. (a) To obtain a license to act as a risk manager in this state, an applicant must submit to the department an application on forms prescribed by the commissioner and provided by the department. (b) An application must be accompanied by the license fee …

Sec. 4153.053. QUALIFICATIONS. To qualify for a risk manager's license, an applicant must: (1) be at least 18 years of age; (2) maintain a place of business in this state; (3) meet the application requirements prescribed by this chapter and department rules; (4) take and pass the…

Sec. 4153.054. EXAMINATION. (a) Except as provided by Sections 4153.055 and 4153.058, an applicant for a risk manager's license must personally take and pass an examination to the satisfaction of the commissioner under this chapter and department rules. (b) The commissioner shall…

Sec. 4153.055. EXEMPTIONS FROM EXAMINATION AND CONTINUING EDUCATION REQUIREMENT. (a) An applicant is not required to take an examination to obtain a risk manager's license if the applicant holds the designation of: (1) chartered property casualty underwriter (CPCU) from the Ameri…

Sec. 4153.056. REEXAMINATION. (a) An applicant who fails the examination may retake the examination on payment of an additional examination fee. (b) The commissioner may require the applicant to wait for a reasonable period determined by the commissioner before the applicant may …

Sec. 4153.057. FEES. (a) The commissioner shall set and collect in advance a nonrefundable fee, in an amount not to exceed $50, for: (1) an examination required by this chapter if the department administers the examination; (2) a risk manager's license; and (3) the renewal of a r…

Sec. 4153.058. RECIPROCAL LICENSE. On submission of an application and the license fee required by Section 4153.057, a person may receive a risk manager's license without examination if the person is licensed as a risk manager by another state, the licensing requirements of which…

Sec. 4153.059. LICENSE EXPIRATION. Except as otherwise provided by a staggered renewal system adopted under Section 4003.002, a risk manager's license expires on the second anniversary of the date the license was issued. Added by Acts 2003, 78th Leg., ch. 1274, Sec. 7, eff. April…

Sec. 4153.060. LICENSE RENEWAL. (a) A license holder may renew an unexpired license by: (1) filing with the department a completed renewal application; and (2) paying the nonrefundable renewal fee. (b) The commissioner shall issue a renewal certificate to the license holder if th…

Sec. 4153.101. PLACE OF BUSINESS. A license holder shall maintain a place of business in this state that is: (1) accessible to the public; and (2) located at the place at which the license holder principally conducts business. Added by Acts 2003, 78th Leg., ch. 1274, Sec. 7, eff.…

Sec. 4153.102. NOTIFICATION OF CHANGE OF PLACE OF BUSINESS. A license holder who changes the address of the license holder's place of business from the address that appears on the license shall notify the department of that change as provided by department rules. Added by Acts 20…

Sec. 4153.151. GROUNDS FOR DISCIPLINARY ACTION. The department may discipline a license holder or deny an applicant a license under Subchapter C, Chapter 4005: (1) for any cause for which, if known by the department, issuance of the license could have been refused; or (2) if the …

Sec. 4153.152. LICENSE SUSPENSION. (a) An order suspending a license must specify the duration of the suspension period. The department may not suspend a license for a period of more than 12 months. (b) A license holder whose license is revoked or suspended shall surrender the li…

Sec. 4153.153. REINSTATEMENT OR REISSUANCE OF LICENSE. The commissioner may not reinstate the license of or reissue a license to a person whose license is suspended or revoked or to whom the department refuses to issue a renewal certificate until the first anniversary of the date…

Sec. 4201.001. PURPOSE. The purpose of this chapter is to: (1) promote the delivery of quality health care in a cost-effective manner; (2) ensure that a utilization review agent adheres to reasonable standards for conducting utilization review; (3) foster greater coordination and…

Sec. 4201.002. DEFINITIONS. In this chapter: (1) "Adverse determination" means a determination by a utilization review agent that health care services provided or proposed to be provided to a patient are not medically necessary or appropriate or are experimental or investigationa…

Sec. 4201.003. RULES. (a) The commissioner may adopt rules to implement this chapter. (b) A rule adopted under this chapter relates only to a person or entity subject to this chapter. (c) Repealed by Acts 2011, 82nd Leg., R.S., Ch. 1147, Sec. 2.008(11), eff. September 1, 2011. (d…

Sec. 4201.004. TELEPHONE ACCESS. (a) A utilization review agent shall: (1) have appropriate personnel reasonably available, by toll-free telephone at least 40 hours per week during normal business hours in this state, to discuss patients' care and allow response to telephone revi…

Sec. 4201.051. PERSONS PROVIDING INFORMATION ABOUT SCOPE OF COVERAGE OR BENEFITS. This chapter does not apply to a person who: (1) provides information to an enrollee about scope of coverage or benefits provided under a health insurance policy or health benefit plan; and (2) does…

Sec. 4201.052. CERTAIN CONTRACTS WITH FEDERAL GOVERNMENT. This chapter does not apply to a contract with the federal government to provide utilization review with respect to a patient who is eligible for services under Title XVIII or XIX of the Social Security Act (42 U.S.C. Sect…

Sec. 4201.053. MEDICAID AND OTHER STATE HEALTH OR MENTAL HEALTH PROGRAMS. (a) Except as provided by Section 4201.057, this chapter does not apply to: (1) the state Medicaid program; (2) the services program for children with special health care needs under Chapter 35, Health and …

Sec. 4201.054. WORKERS' COMPENSATION BENEFITS. (a) Except as provided by this section, this chapter applies to utilization review of a health care service provided to a person eligible for workers' compensation medical benefits under Title 5, Labor Code. The commissioner of worke…

Sec. 4201.055. HEALTH CARE SERVICE PROVIDED UNDER AUTOMOBILE INSURANCE POLICY. This chapter does not apply to utilization review of a health care service provided under an automobile insurance policy or contract that is authorized under Chapter 2301 or Article 5.13-2 or that is i…

Sec. 4201.056. EMPLOYEE WELFARE BENEFIT PLANS. This chapter does not apply to the terms or benefits of an employee welfare benefit plan defined by Section 3(1) of the Employee Retirement Income Security Act of 1974 (29 U.S.C. Section 1002(1)). Added by Acts 2005, 79th Leg., Ch. 7…

Sec. 4201.057. HEALTH MAINTENANCE ORGANIZATIONS. (a) In this section, "health maintenance organization" includes a health maintenance organization that contracts with the Health and Human Services Commission or with an agency operating part of the state Medicaid managed care prog…

Sec. 4201.058. INSURERS. (a) This chapter applies to an insurer subject to this code that delivers or issues for delivery a health insurance policy in this state except as expressly provided by this section. As a condition of holding a certificate of authority to engage in the bu…

Sec. 4201.101. CERTIFICATE OF REGISTRATION REQUIRED. A utilization review agent may not conduct utilization review unless the commissioner issues a certificate of registration to the agent under this subchapter. Added by Acts 2005, 79th Leg., Ch. 727 (H.B. 2017), Sec. 4, eff. Apr…

Sec. 4201.102. REQUIREMENTS FOR CERTIFICATION. (a) The commissioner may issue a certificate of registration only to an applicant who has met all the requirements of this chapter and all applicable rules adopted by the commissioner. (b) As a condition of holding a certificate of r…

Sec. 4201.103. CERTIFICATE RENEWAL. Certification may be renewed biennially by filing, not later than March 1, a renewal form with the commissioner accompanied by a fee in an amount set by the commissioner. Added by Acts 2005, 79th Leg., Ch. 727 (H.B. 2017), Sec. 4, eff. April 1,…

Sec. 4201.104. CERTIFICATION AND RENEWAL FORMS. (a) The commissioner shall promulgate forms to be filed under this subchapter for initial certification and for a renewal certificate of registration. The form for initial certification must require: (1) the utilization review agent…

Sec. 4201.105. FEES. The commissioner shall establish, administer, and enforce the fees for initial certification and certification renewal in amounts that do not exceed the amounts necessary to cover the cost of administering this chapter. Added by Acts 2005, 79th Leg., Ch. 727 …

Sec. 4201.106. CERTIFICATE NOT TRANSFERABLE. A certificate of registration is not transferable. Added by Acts 2005, 79th Leg., Ch. 727 (H.B. 2017), Sec. 4, eff. April 1, 2007.

Sec. 4201.107. REPORTING MATERIAL CHANGES. A utilization review agent shall report any material change to the information disclosed in a form filed under this subchapter not later than the 30th day after the date the change takes effect. Added by Acts 2005, 79th Leg., Ch. 727 (H.…

Sec. 4201.108. LIST OF UTILIZATION REVIEW AGENTS. (a) The commissioner shall maintain and update monthly a list of each utilization review agent to whom a certificate of registration has been issued and the renewal date of the certificate. (b) The commissioner shall provide the l…

Sec. 4201.151. UTILIZATION REVIEW PLAN. A utilization review agent's utilization review plan, including reconsideration and appeal requirements, must be reviewed by a physician licensed to practice medicine in this state and conducted in accordance with standards developed with i…

Sec. 4201.152. UTILIZATION REVIEW UNDER DIRECTION OF PHYSICIAN. A utilization review agent shall conduct utilization review under the direction of a physician licensed to practice medicine in this state. The physician may not hold a license to practice administrative medicine und…

Sec. 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, includ…

Sec. 4201.154. REVIEW AND INSPECTION OF SCREENING CRITERIA AND REVIEW PROCEDURES. (a) A utilization review agent's written screening criteria and review procedures shall be made available for: (1) review and inspection to determine appropriateness and compliance as considered nec…

Sec. 4201.155. LIMITATION ON NOTICE REQUIREMENTS AND REVIEW PROCEDURES. (a) A utilization review agent may not establish or impose a notice requirement or other review procedure that is contrary to the requirements of the health insurance policy or health benefit plan. (b) This s…

Sec. 4201.156. USE OF AUTOMATED DECISION SYSTEM FOR ADVERSE DETERMINATIONS. (a) A utilization review agent may not use an automated decision system to make, wholly or partly, an adverse determination. (b) The commissioner may audit and inspect at any time a utilization review age…

Sec. 4201.201. REPETITIVE CONTACTS WITH HEALTH CARE PROVIDER OR PATIENT; FREQUENCY OF REVIEWS. A utilization review agent: (1) may not engage in unnecessary or unreasonable repetitive contacts with a health care provider or patient; and (2) shall base the frequency of contacts or…

Sec. 4201.202. OBSERVING OR PARTICIPATING IN PATIENT'S CARE. (a) Unless approved for an individual patient by the provider of record or modified by contract, a utilization review agent shall be prohibited from observing, participating in, or otherwise being present during a patie…

Sec. 4201.203. MENTAL HEALTH THERAPY. (a) A utilization review agent may not require, as a condition of treatment approval or for any other reason, the observation of a psychotherapy session or the submission or review of a mental health therapist's process or progress notes. (b)…