The Texas Department of Insurance (TDI) reminds health maintenance organizations, health insurers, workers' compensation insurance carriers, and utilization review agents (URAs) that an adverse determination, or a workers' compensation utilization review determination, based on a health care service being experimental or investigational is subject to the utilization review requirements in Texas law. See Texas Insurance Code Chapters 4201 and 4202 and Title 28, Texas Administrative Code, Chapter 19, Subchapters R and U.
Health plan issuers, workers’ compensation insurance carriers, and URAs should review and ensure compliance with the requirements by:
- Using appropriate personnel, screening criteria, and procedures;
- Issuing adverse determination notices in the time allowed; and
- Providing the information required in adverse determination notices.
TDI will continue to monitor compliance with utilization review requirements. Failure to comply with these requirements may result in disciplinary action and administrative penalties as provided in the Insurance Code and TDI rules.