All codes › Insurance Code › Title 14

Chapter 4201

Utilization Review Agents

Subchapter A. General Provisions

4201.001 Purpose 4201.002 Definitions 4201.003 Rules 4201.004 Telephone Access

Subchapter B. Applicability of Chapter

4201.051 Persons Providing Information About Scope of Coverage or Benefits 4201.052 Certain Contracts with Federal Government 4201.053 Medicaid and Other State Health or Mental Health Programs 4201.054 Workers' Compensation Benefits 4201.055 Health Care Service Provided under Automobile Insurance Policy 4201.056 Employee Welfare Benefit Plans 4201.057 Health Maintenance Organizations 4201.058 Insurers

Subchapter C. Certification

4201.101 Certificate of Registration Required 4201.102 Requirements for Certification 4201.103 Certificate Renewal 4201.104 Certification and Renewal Forms 4201.105 Fees 4201.106 Certificate Not Transferable 4201.107 Reporting Material Changes 4201.108 List of Utilization Review Agents

Subchapter D. Utilization Review: General Standards

4201.151 Utilization Review Plan 4201.152 Utilization Review under Direction of Physician 4201.153 Screening Criteria and Review Procedures 4201.154 Review and Inspection of Screening Criteria and Review Procedures 4201.155 Limitation on Notice Requirements and Review Procedures 4201.156 Use of Automated Decision System for Adverse Determinations

Subchapter E. Utilization Review: Relations with Patients and Health Care Providers

4201.201 Repetitive Contacts with Health Care Provider or Patient; Frequency of Reviews 4201.202 Observing or Participating in Patient's Care 4201.203 Mental Health Therapy 4201.204 Complaint System 4201.205 Designated Initial Contact 4201.206 Opportunity to Discuss Treatment Before Adverse Determination 4201.207 Charges by Health Care Provider for Providing Medical Information

Subchapter F. Utilization Review: Personnel

4201.251 Delegation of Utilization Review 4201.252 Personnel 4201.253 Prohibited Bases for Employment, Compensation, Evaluations, or Performance Standards

Subchapter G. Notice of Determinations

4201.301 General Duty to Notify 4201.302 General Time for Notice 4201.303 Adverse Determination: Contents of Notice 4201.304 Time for Notice of Adverse Determination 4201.305 Notice of Adverse Determination for Retrospective Utilization Review

Subchapter H. Appeal of Adverse Determination

4201.351 Complaint as Appeal 4201.352 Written Description of Appeal Procedures 4201.353 Appeal Procedures Must Be Reasonable 4201.354 Persons or Entities Who May Appeal 4201.355 Acknowledgment of Appeal 4201.356 Decision by Physician Required; Specialty Review 4201.357 Expedited Appeal for Denial of Emergency Care, Continued Hospitalization, Prescription Drugs or Intravenous Infusions 4201.358 Response Letter to Interested Persons 4201.359 Notice of Appeal 4201.360 Immediate Appeal to Independent Review Organization in Life-Threatening Circumstances 4201.3601 Immediate Appeal to Independent Review Organization for Denial of Prescription Drugs or Intravenous Infusions

Subchapter I. Independent Review of Adverse Determination

4201.401 Review by Independent Review Organization; Compliance with Independent Determination 4201.402 Information Provided to Independent Review Organization 4201.403 Payment for Independent Review

Subchapter J. Specialty Utilization Review Agents

4201.451 Definition 4201.452 Inapplicability of Certain Other Law 4201.453 Utilization Review Plan 4201.454 Utilization Review under Direction of Provider of Same Specialty 4201.455 Personnel 4201.456 Opportunity to Discuss Treatment Before Adverse Determination 4201.457 Appeal Decisions

Subchapter L. Confidentiality of Information; Access to Other Information

4201.551 General Confidentiality Requirement 4201.552 Consent Requirements 4201.553 Providing Information to Affiliated Entities 4201.554 Providing Information to Commissioner 4201.555 Access to Recorded Personal Information 4201.556 Publishing Information Identifiable to Health Care Provider 4201.557 Requirement to Maintain Data in Confidential Manner 4201.558 Destruction of Certain Confidential Documents

Subchapter M. Enforcement

4201.601 Notice of Suspected Violation; Compelling Production of Information 4201.602 Enforcement Proceeding 4201.603 Remedies and Penalties for Violation

Subchapter N. Exemption from Preauthorization Requirements for Physicians and Providers Providing Certain Health Care Services

4201.651 Definitions 4201.652 Applicability of Subchapter 4201.653 Exemption from Preauthorization Requirements for Physicians and Providers Providing Certain Health Care Services 4201.654 Duration of Preauthorization Exemption 4201.655 Denial or Rescission of Preauthorization Exemption 4201.656 Independent Review of Exemption Determination 4201.657 Effect of Appeal or Independent Review Determination 4201.658 Eligibility for Preauthorization Exemption Following Finalized Exemption Rescission or Denial 4201.659 Effect of Preauthorization Exemption 4201.660 Report