Texas Register, Volume 22, Number 80, Pages 12189-12342, December 12, 1997 Page: 12,262
12189-12342 p. ; 28 cm.View a full description of this periodical.
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This agency hereby certifies that the adoption has been re-
viewed by legal counsel and found to be a valid exercise of the
agency's legal authority.
Issued in Austin, Texas, on November 25, 1997.
TRD-9715899
Katherine A. Thomas, MN, RN
Executive Director
Board of Nurse Examiners
Effective date: January 1, 1998
Proposal publication date: October 17, 1997
For further information, please call: (512) 305-6811
TITLE 28. INSURANCE
Part I. Texas Department of Insurance
Chapter 19. Agents Licensing
Subchapter R. Utilization Review Agents
28 TAC 19.1702-19.1721
The Commissioner of Insurance adopts amendments to
Chapter 19, concerning utilization review agents, by amending
19.1702-19.1719 and adding new 19.1720 and 19.1721.
Amendments to 19.1702, 19.1704, 19.1705, 19.1710,
19.1712 - 19.1714, 19.1716, 19.1719 and new 19.1721 are
adopted with changes to the proposed text as published in the
September 5, 1997 issue of the Texas Register (22 TexReg
8863). Sections 19.1703, 19.1706, 19.1707, 19.1708, 19.1709,
19.1711, 19.1715, 19.1717, 19.1718, and 19.1720 are adopted
without changes and will not be republished.
These amendments are necessary to implement provisions of
the Insurance Code Article 21.58A, amended by Senate Bills
384 and 386, enacted by Acts, 75th Legislature, 1997, and cod-
ified at Texas Insurance Code Article 21.58A, effective Septem-
ber 1, 1997, relating to health care utilization review agents
and independent review of adverse determinations. In addi-
tion, the amendments are necessary to promote the consistent
delivery of quality health care in a cost-effective manner by re-
quiring utilization review agents to adhere to such standards
when conducting reviews. The amendments are necessary to
ensure an efficient and effective appeals process for the re-
view of utilization review decisions. The new sections establish
specialty review utilization review agents and requirements for
their licensing, and set forth the obligations of utilization review
agents regarding requests for independent review by indepen-
dent review organizations. The sections provide clarification
concerning utilization review agent's licensure and renewal and
reporting requirements of utilization review agents.
After receiving public comments on the proposed amendments
to Chapter 19, the department has made the following changes.
Based on comments, the department has deleted language in
19.1702(b) to clarify licensing requirements for an insurer or
HMO. Consistent with these changes, the department has also
changed 19.1719(a)(3) and (b)(4) to clarify the information that
is to be submitted by insurers and HMOs which must register
with the department.
Based on comments, the department has deleted language in
19.1702(c) which stated, "This subchapter does not affect the
authority of the Texas Workers' Compensation Commission toexercise the powers granted to that commission under Title
5, Labor Code," and has renumbered prior subsection (d) as
(c). It has also added language to 19.1702(c)(3)(C) stating
that the subchapter does not apply to reviews of health care
services provided to patients under the authority of the Texas
Workers' Compensation Act. These recommended changes
were made pursuant to House Bill 3197, 75th Texas Legislature,
which amended Article 21.58A to require regulation of utilization
review of a medical benefit under the workers' compensation
act, but which states it does not affect the authority of the
Texas Workers' Compensation Commission (TWCC) to exercise
the powers granted under its statute, which prevails in the
event of a conflict. However, the department has determined
that these rules will not apply to utilization review of workers'
compensation benefits, and that instead it will, in cooperation
with TWCC, propose rules specific to workers' compensation
utilization review. Those rules will specify which provisions of
Article 21.58A apply to such review, and which are in conflict
with the workers' compensation act and therefore subject to the
latter statute.
Changes were made in response to comments on
19.1704(c)(12) and (d) to clarify that biographical data
on each person conducting utilization review, such as physi-
cians or nurses, is not necessary. For purposes of consistency
with these changes, 19.1704(c)(6) and 19.1706(c) were
changed to require applicants for certification to submit the
names of personnel employed or contracted to perform
utilization review.
New subsection (i) has been added to 19.1704, in response to
a comment, to provide that utilization review agents that were
certified prior to the adoption of these rules must file with the
department all changes to their original applications necessi-
tated by these rules by March 1, 1998. In addition, pursuant to
a comment the department has clarified the meaning of "spe-
cial circumstances" in 19.1705(2)(A), and has eliminated ref-
erence to "complex conditions," which it believes are encom-
passed within the scope of special circumstances.
Clarifying language was added to 19.1705(2)(H)(iv),
19.1712(b)(2) and (5) and 19.1713(c), in response to com-
ments; other clarifying language was added to 19.1705(4)
and 19.1721(c). Typographical errors were corrected in
19.1710(b) and 19.1716(b)(7). New subsection (c)(5) was
added to 19.1710 to clarify what must be included in the
notice of adverse determination. In response to a comment,
19.1710(e) and 19.1721(a) were changed to clarify that
notification must be provided to an enrollee or person acting
on the enrollee's behalf.
Pursuant to comment, 19.1714(b) was changed to specify that
personal information, for purposes of confidentiality, shall in-
clude at a minimum a person's name, address, phone num-
ber, social security number, and financial information. In
19.1716(b)(6), the requirement was deleted that a utilization
review agent provide to the department certain information con-
cerning referrals to independent review organizations, and para-
graph (7) was renumbered accordingly. Section 19.1719(a)(3)
added language in response to comments and subsection(b)(4)
was changed to be consistent with (a)(3). Section 19.1721(c)
was changed to clarify that a utilization review agent shall per-
mit any party whose appeal is denied by the utilization review
agent to seek review of the determination by an independent
review organization.22 TexReg 12262 December 12, 1997 Texas Register
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Texas. Secretary of State. Texas Register, Volume 22, Number 80, Pages 12189-12342, December 12, 1997, periodical, December 12, 1997; Austin, Texas. (https://texashistory.unt.edu/ark:/67531/metapth176721/m1/76/: accessed July 18, 2024), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu; crediting UNT Libraries Government Documents Department.