ADOPTED RULES
An agency may take final action on a section 30 days after a proposal has been 
published in the Texas Register. The section becomes effective 20 days after the 
agency files the correct document with the Texas Register, unless a later date 
is specified or unless a federal statute or regulation requires implementation 
of the action on shorter notice.
If an agency adopts the section without any changes to the proposed text, only 
the preamble of the notice and statement of legal authority will be published. 
If an agency adopts the section with changes to the proposed text, the proposal 
will be republished with the changes.

TITLE 22. EXAMINING BOARDS
PART XI. Board of Nurse Examiners
CHAPTER 215.Nurse Education
22 TAC sec.215.15
The Board of Nurse Examiners adopts amendments to sec.215.15 concerning Students 
with changes to the proposed text as published in the October 17, 1997, issue of 
the Texas Register (22 TexReg 10233). The change deletes the phrase "accepted 
for enrollment or" to require the rule to apply only to those students already 
enrolled in the nursing program.
The amendments are being adopted to implement Senate Bill 617 which became 
effective September 1, 1997. The statutory change allows the Board to require 
schools of nursing to ensure that individuals enrolled in nursing programs in 
Texas are informed of eligibility criteria and potential bars to licensure. The 
adopted amendments will implement Senate Bill 617 in a manner that provides 
flexibility for the nursing programs, minimizes reporting requirements to the 
Board, and maintains a record that enrollees have been informed of eligibility 
issues and the Declaratory Order Process. Unless requested by the Board, 
documents will be maintained with student files or in a manner to be determined 
by the nursing programs. 
The proposed amendments were shared with deans and directors of nursing programs 
during their annual meeting in September, 1997. At that meeting, the deans and 
directors voiced concerns regarding verbally informing individuals accepted for 
enrollment about the eligibility issues, rather than only those enrolled. In 
addition, clarification was requested regarding which nursing programs would be 
required to inform enrollees about eligibility issues since students enrolled in 
RN-BSN completion programs or tracks are already RNs and do not need 
notification of the requirement. Lastly, they were concerned about developing 
their own form and suggested that an official Board form be created. A written 
comment was received from Texas Woman's University, stating that the term 
"individuals accepted for enrollment" was cumbersome and probably impossible to 
implement. 
The Board agreed with the comments and modified the rule accordingly.
The amendments are adopted under the Nursing Practice Act, (Texas Civil 
Statutes, Article 4514), sec.1, which provides the Board of Nurse Examiners with 
the authority and power to make and enforce all rules and regulations necessary 
for the performance of its duties and conducting of proceedings before it and 
Article 4519a, sec.1, which states that an individual enrolled or planning to 
enroll in an educational program that prepares an individual for an initial 
license as a registered nurse who has reason to believe that the individual is 
ineligible for the license may petition the board for a declaratory order as to 
the individual's eligibility. 
There are no other rules, codes, or statutes that will be affected by this 
proposal. Education sec.215 

sec.215.15.Students. 
(a)-(e) (No change.) 
(f) Individuals enrolled in accredited professional nursing programs preparing 
students for initial licensure shall be provided verbal and written information 
regarding conditions that may disqualify graduates from licensure and of their 
rights to petition the Board for a Declaratory Order of Eligibility. 
(1) Required eligibility information includes: 
(A) Texas Civil Statutes, Articles 4519a and 4525; 
(B) Rules 213.27-213.30 of this Chapter (relating to Good Professional 
Character, Licensure of Persons with Criminal Convictions, Eligibility and 
Disciplinary Criteria Regarding Intemperate Use and Lack of Fitness and 
Declaratory Order of Eligibility for Licensure; and 
(C) Declaratory Order Petition Request Form. 
(2) Written receipt of the required information shall be documented on the 
Licensure Eligibility Form which contains, at a minimum, the following board 
approved elements: 
(A) name, date of birth, and social security number of the individual enrolled 
in the accredited professional nursing program; 
(B) statement that the information cited in sec.215.15(f)(1) of this section 
(relating to Students) was received and explained; and 
(C) signature of the individual who received the information and date of 
receipt. 
(3) Records documenting the receipt of the required information shall be 
maintained by the nursing program until six months after the individual enrolled 
completes the nursing program or permanently withdraws from the nursing program. 
(4) The Director of the Nursing Program shall submit an affidavit each year with 
the Annual Report that all individuals enrolled in the accredited nursing 
program received the required eligibility information, that it was explained to 
the students, and that the forms documenting that receipt were signed and 
maintained by the nursing program.
This agency hereby certifies that the adoption has been reviewed 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 sec.sec.19.1702-19.1721
The Commissioner of Insurance adopts amendments to Chapter 19, concerning 
utilization review agents, by amending sec.sec.19.1702-19.1719 and adding new 
sec.sec.19.1720 and 19.1721. Amendments to sec.sec.19.1702, 19.1704, 19.1705, 
19.1710, 19.1712 - 19.1714, 19.1716, 19.1719 and new sec.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 codified at Texas Insurance Code Article 21.58A, 
effective September 1, 1997, relating to health care utilization review agents 
and independent review of adverse determinations. In addition, the amendments 
are necessary to promote the consistent delivery of quality health care in a 
cost-effective manner by requiring 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 review 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 
independent 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 sec.19.1702(b) to clarify licensing requirements for an 
insurer or HMO. Consistent with these changes, the department has also changed 
sec.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 sec.19.1702(c) which stated, "This 
subchapter does not affect the authority of the Texas Workers' Compensation 
Commission to exercise 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 sec.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 sec.19.1704(c)(12) and (d) to 
clarify that biographical data on each person conducting utilization review, 
such as physicians or nurses, is not necessary. For purposes of consistency with 
these changes, sec.sec.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 sec.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 necessitated by these rules by March 1, 1998. In addition, pursuant 
to a comment the department has clarified the meaning of "special circumstances" 
in sec.19.1705(2)(A), and has eliminated reference to "complex conditions," 
which it believes are encompassed within the scope of special circumstances. 
Clarifying language was added to sec.sec.19.1705(2)(H)(iv), 19.1712(b)(2) and 
(5) and 19.1713(c), in response to comments; other clarifying language was added 
to sec.sec.19.1705(4) and 19.1721(c). Typographical errors were corrected in 
sec.sec.19.1710(b) and 19.1716(b)(7). New subsection (c)(5) was added to 
sec.19.1710 to clarify what must be included in the notice of adverse 
determination. In response to a comment, sec.sec.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, sec.19.1714(b) was changed to specify that personal 
information, for purposes of confidentiality, shall include at a minimum a 
person's name, address, phone number, social security number, and financial 
information. In sec.19.1716(b)(6), the requirement was deleted that a 
utilization review agent provide to the department certain information 
concerning referrals to independent review organizations, and paragraph (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 permit 
any party whose appeal is denied by the utilization review agent to seek review 
of the determination by an independent review organization. 
Section 19.1702(b) establishes the applicability of the Act to licensed HMOs. 
Section 19.1703 amends the definitions of "administrative procedure act," 
"appeal process," "complaint," "inquiry," "life-threatening," and "practicing 
healthcare provider" to clarify the meaning of the amendments. The section also 
redefines "emergency care," "open records law," and "provider of record" to make 
this section consistent with the amendments. 
Section 19.1704 establishes a new address where applications for utilization 
review licensing must be submitted, requires that certain screening criteria 
requirements comply with the Act and the absence of certain compensation 
arrangements be certified by an authorized representative of the company, 
requires establishment of procedures for handling both oral and written 
complaints by enrollees, patients, or health care providers, specifies that 
samples of utilization review materials submitted with applications must include 
language for notification of an adverse determination made in a utilization 
review, sets forth specific documentation to be submitted with all applications 
for utilization review licensure, and defines "material changes" for reporting 
purposes. Amendments to this section also clarify the timeframes in which the 
department must respond to applications and the timeframes and requirements for 
application of renewal by the utilization review agent. 
Section 19.1705, as amended, requires that practicing physicians and health care 
providers have input into the development of a utilization review plan and that 
the plan include written procedures for identification of individuals with 
special circumstances who may require flexibility in the application of 
screening criteria. This section requires prior written notice to a physician or 
health care provider when publishing certain data which identifies a particular 
physician or health care provider. This section also sets forth certain criteria 
for utilization review decisions, and requires referral to an appropriate 
"dentist" or "health care provider" performing utilization review under certain 
circumstances. Amendments to this section also provide that delegation of review 
to a hospital utilization review program does not relieve the utilization review 
agent of full responsibility for compliance with this subchapter.
Amendments to sec.19.1706 specify which information obtained from a physician, 
dentist or health care provider, must be obtained by specifically qualified 
personnel. Amendments to this section also provide that a physician directing 
utilization review for a utilization review agent may be employed by or under 
contract to the utilization review agent. A new subsection (f) added to 
sec.19.1708 prohibits a utilization review agent's observation of a 
psychotherapy session or access to mental health therapists' process or progress 
notes, although it specifically does not preclude the agent from requiring 
submission of the patient's medical record. 
Amendments to sec.19.1710 require that a notification of adverse determination 
by a utilization review agent include the clinical basis for the determination 
and information concerning the independent review process. The amendments also 
provide that telephonic or electronic transmissions of notice where the patient 
is hospitalized be followed by a letter within three working days, that notice 
denying post-stabilization care subsequent to emergency treatment be given 
within the time appropriate to the circumstances, for life-threatening 
conditions, the timeframes for notice set forth in subsection (d) of this 
section apply. 
Amendments to sec.19.1712 provide that an adverse determination may be appealed 
orally or in writing, and require the utilization review agent to acknowledge 
receipt of the appeal within five days. Amendments to this section also provide 
that dentists may, when appropriate, make appeal decisions, and also impose a 
period of 15 working days for completion of specialty review. These amendments, 
additionally, require that the utilization review agent maintain a method of 
expedited appeal for denials of care in life-threatening conditions, and require 
that utilization review agents issue response letters to patients explaining the 
resolution of the appeals. Amendments to this section also provide that in 
circumstances involving a life-threatening condition, there may be an immediate 
appeal to an independent review organization. 
Amendments to sec.19.1713 require a utilization review agent to provide to the 
commissioner a written description of procedures for responding to requests for 
post-stabilization care subsequent to emergency treatment. Amendments to 
sec.19.1714 require that authorization for release of confidential information 
submitted by anyone other than the individual who is the subject of the 
information requested must contain the signature of such individual and be dated 
within the past year. The amendments also set forth requirements of a 
utilization review agent in responding to such requests, and permissible charges 
therefor. Finally, the amendments maintain that the commissioner is entitled to 
such information from the utilization review agent upon request. An explanation 
of what constitutes minimum personal information was also included.
Amendments to sec.19.1716 add the requirements that the utilization review 
agent's summary report of written complaints must include the total number of 
written notices of adverse determinations, and set forth the specific 
requirements for listing appeals of adverse determinations in the summary report 
and the classifications of appellants. The amendments also require utilization 
review agents to respond to complaints within 30 days of their receipt and 
require the maintenance of records for three years from the time complaints are 
filed. Section 19.1717, as amended, includes the HMO or insurer as parties which 
shall be notified by the commissioner or the commissioner's designated 
representative of any alleged violations of the Act, and allows the commissioner 
to assess administrative penalties under the Insurance Code Article 1.10E. 
Section 19.1719, as amended, requires HMOs and insurers performing utilization 
review under Section 14(g) and (h) of the Act to register with the department. 
It also sets forth the specific portions of this subchapter to which HMOs and 
insurers performing utilization review under the Insurance Code Article 21.58A, 
sec.14(g) and (h) will be subject, and requires that they submit written 
documentation to the department demonstrating compliance with all filing 
requirements required of utilization review agents. The amendments also include 
HMOs that contract with the Health and Human Services Commission or any agency 
operating part of the state Medicaid managed care program. The amendments also 
subject HMOs and insurers performing utilization review under the Insurance Code 
Article 21.58A, sec.14(g) and (h) to assessment of maintenance taxes under the 
Insurance Code. 
Section 19.1720 establishes specialty utilization review agents and sets forth 
the requirements for their licensure, and standards for specialty review. 
Section 19.1721 sets forth the obligations of utilization review agents for 
requesting and facilitating independent review by an independent review 
organization when requested. 
sec.19.1702(b). One commenter suggested that the rules clarify at the beginning 
of this section whether a Health Maintenance Organization (HMO) must obtain a 
license as a utilization review agent. 
Response. The department agrees and has added clarifying language in 
sec.19.1702(b) requiring the filing of documentation with the department to 
assure compliance with the Act as set forth in sec.19.1719. The department has 
made changes to clarify that the name, address, contact name, phone number and 
utilization review plan of the health maintenance organization is to be 
submitted.
sec.sec.19.1702(c), 19.1705 and 19.1719(b)(1). Several commenters suggested that 
there may be possible conflicts between the Labor Code, Title 5, the Texas 
Workers' Compensation Commission rules, and these proposed sections. One 
commenter asked if the spinal surgery second opinion process, as outlined in the 
Texas Labor Code and Texas Workers' Compensation Commission rules conflicts with 
the proposed Chapter 19 rules. A commenter questioned whether the Texas Workers' 
Compensation Commission medical dispute resolution process conflicts with TDI 
provisions governing appeals and/or written procedures. Some commentors 
suggested that the deletion of the language excluding workers' compensation from 
the scope of the rules either be postponed until such time as rules for workers' 
compensation may be adopted or that language be added to clarify that the 
utilization review rules are not applicable to workers' compensation until 
additional rules are adopted. The commentors stated that the inclusion of these 
provisions could create ambiguity and misunderstanding as to the appropriate 
utilization review requirements for workers' compensation. 
One commenter asked whether the Texas Labor Code Section 413.011(a)(2), 
concerning treatment guidelines, conflicts with proposed sec.19.1705(3). The 
commenter also asked that the agency clarify whether the limitation on the 
liability of workers' compensation carriers for medical benefits established by 
Texas Labor Code Section 408.021 conflicts with proposed sec.19.1705.
One commenter asked that the department clarify whether the department intends 
proposed sec.19.1719(b)(1) to apply to a workers' compensation carrier that 
delivers or issues for delivery a workers' compensation policy in Texas and 
performs utilization review. 
Response. The department has deleted language proposed in sec.19.1702(c), 
regarding the authority of the Texas Workers' Compensation Commission, and has 
renumbered the remaining subsection accordingly. It has also added language 
stating that the subchapter does not apply to review of health care services 
provided to patients under the authority of the Texas Workers' Compensation Act. 
This change is made pursuant to House Bill 3197, 75th Texas Legislature, which 
amended the Insurance Code 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 to exercise the powers granted under its statute, which prevails in 
the event of a conflict. Accordingly, the department, in cooperation with the 
Texas Workers' Compensation Commission, will propose rules specific to workers' 
compensation utilization review, which will specify which provisions of the 
Insurance Code Article 21.58A apply to such review, and which provisions are in 
conflict with the Texas Workers' Compensation Act and therefore subject to the 
latter statute. 
sec.19.1702(d)(3)(B). One commenter suggested that the rules be clarified to 
ensure that the utilization review rules apply to the Primary Care Case 
Management (PCCM) program. The commenter stated that the Medicaid PCCM managed 
care utilization review activities are essentially similar to the utilization 
reviews performed by HMOs and are performed for the Texas Medicaid program by 
contract with an agency operating part of the state Medicaid managed care 
program. The commenter also noted that in some Medicaid service areas PCCM is a 
larger managed care system than the HMO model. 
Response. The department disagrees. The Primary Care Case Management model is a 
state administered model and does not fall within the definition of an HMO. The 
Medicaid program is specifically exempted from compliance with the Act. 
sec.19.1703 Adverse Determination. One commenter recommended using the 
definition of adverse determination found in Senate Bills 384 and 386. 
Response. The department believes that the definition of "adverse determination" 
complies with the legislative intent of Senate Bills 384 and 386 by clarifying 
that all adverse determinations, whether based on medical necessity or 
appropriateness of the recommended treatment, are subject to the appeals process 
and independent review. The department wants to ensure that the utilization 
review process is not used to ration health care by denying treatment simply 
because it is costly. 
sec.19.1703. Emergency Care. One commenter requested that the "emergency care" 
definition clarify what would be considered "recent onset," and asked whether 
the definition excludes care rendered in an inpatient setting. The commenter 
requested additional guidance as to how the components of the definition apply 
to behavioral health services. 
Response. The phrase "recent onset and severity" indicates that the patient's 
condition reached a severity level such that the patient would be led, as a 
prudent layperson, to believe that immediate medical care was needed. The 
department believes that the language is clear, yet not restrictive. The 
definition of emergency care primarily includes care rendered in a hospital 
emergency room setting. 
sec.19.1703. Life-threatening. Two commentors recommended that the department 
clarify the applicability of the definition of "life-threatening" to behavioral 
health services. One commenter suggested amending the definition of "life-
threatening" to include language that the likelihood of death is probable and 
imminent unless the course of the disease or condition is immediately 
interrupted.
Response. The department is reviewing the statutory definitions in relation to 
behavioral health services and is working with the Texas Department of Mental 
Health and Mental Retardation to develop guidelines for behavioral health 
services. The definition of "life-threatening" is statutory and the department 
does not believe that clarifying language is necessary. 
sec.19.1703. Open Records Law. One commenter suggested that the word "patient" 
seems to have been inadvertently included. 
Response. The reason for the comment is unclear, as it does not appear that the 
published rule included "patient" inappropriately. 
sec.19.1704. One commenter suggested that the section require additional items 
to be submitted for continued licensure. The commenter inquired whether the 
other items must be furnished when the adopted rules become effective or at the 
time of license renewal. 
Response. Clarifying language has been added to require that a currently 
licensed utilization review agent file additional items with the department by 
March 1, 1998. 
sec.19.1704(c)(11). One commenter suggested that there is no specific directive 
in Senate Bill 384 for utilization review agents to submit organizational and 
biographical information. The commenter asked that the department identify the 
statutory source of the language. 
Response. This information is requested due to the requirements of Senate Bill 
386 (Texas Insurance Code Article 21.58A(6A) and Article 21.58C(2)) which 
requires the department to assure the independence of the independent review 
organization review process. This information is needed to perform conflict 
checks with an independent review organization and utilization review agent and 
is also needed to identify the officers, directors and executives during 
licensure of the utilization review agent. 
sec.19.1704(c)(12). One commenter asked if the submission of biographical 
information applies only to physician reviewers; or to physician reviewers, 
nurses and health care providers obtaining medical information; or to all staff. 
If the submission of information applies to all staff, the commenter contends 
this will create massive filing requirements for utilization review agents.
Response. The department recognizes the commenter's concerns regarding the 
required filing of biographical data on "staff," such as physicians, nurses, and 
each person conducting the review. The department agrees that biographical data 
on all persons except officers, directors and executives is not necessary, would 
be administratively burdensome, and has deleted the requirement to submit 
information on "each person conducting utilization review." The department has 
also changed sec.19.1704(c)(6) to be consistent with the change to (c)(12).
sec.19.1705(2)(A). One commenter asked for clarification of the terms "special 
circumstances" and "complex conditions." 
Response. The department has added clarifying language that "special 
circumstance includes, but is not limited to, a person who has a disability, 
acute condition, or life-threatening illness." Because the department believes 
that this definition includes complex conditions, reference to complex 
conditions has been deleted.
sec.19.1705(2)(H)(iv). One commenter suggested that the words "such data" may be 
missing from the sentence ". . . in the case of summary data, shall not be 
considered confidential . . ." 
Response. The department agrees with the commenter and has made the necessary 
clarifying changes. 
sec.19.1705(2)(I). One commenter suggested that to be consistent with 
sec.12.208(c) of the independent review organization rules, utilization review 
agents should be required to not only notify physicians and health care 
providers of their intent to publish provider-specific information but also to 
obtain prior written consent from the affected physicians or health care 
providers. 
Response. The department agrees that the independent review organization rules 
require prior written consent from physicians and health care providers to 
publish provider-specific information; however, this provision mirrors statutory 
language which does not require prior written consent from physicians and other 
health care providers. 
sec.19.1705(3). One commenter suggested that the screening criteria used should 
be accessible to the public and inquired whether making the criteria 
confidential conflicts with the statutory requirement to state the source of the 
screening criteria in the notification of adverse determination.
Response. Screening criteria are not subject to the Open Records Act under 
Article 21.58A sec.4(i). The source of the screening criteria does not 
constitute the entire screening criteria, and releasing the source would not 
subject the screening criteria to release under the Open Records Act. The 
confidentiality provision in the Act does not apply to identification of the 
source that developed the screening criteria. 
sec.19.1706. One commenter questioned if a call to a utilization review agent 
from a facility, admitting/UR department or MDO may be received by an individual 
other than a nurse, physician or health care provider. The commenter pointed out 
that the American Accreditation Healthcare Commission/URAC allows non-clinical 
staff to obtain clinical information. 
Response. The Act now requires that personnel who obtain information regarding a 
patient's specific medical condition, diagnosis and treatment options or 
protocols directly from a physician, dentist or health care provider shall be 
nurses, physician's assistants or other health care providers qualified to 
provide the service. However, the Act allows non-clinical personnel to perform 
clerical or administrative tasks. If the staff answering the phones perform only 
clerical or administrative tasks, such as transferring a call, they need not be 
clinical personnel. 
sec.19.1706(d). One commenter suggested adding clarifying language that the 
utilization review personnel who are under contract be subject to the same rules 
and regulations as the other employees and that the utilization review agent 
retain responsibility for contracted personnel actions and their appropriate 
supervision. 
Response. The department believes the language is clear and that no clarifying 
language is necessary. A utilization review agent, as a licensed entity, is 
responsible for ensuring that all of its operations comply with the Act, 
including the actions of its employees and contracted personnel. 
sec.19.1708(f). Two commentors requested the deletion of this section, which 
they say prohibits observation of psychotherapy sessions or the submission or 
review of a mental health therapist's process or progress notes. It is one 
commenter's belief that this provision will create a significant impediment to 
utilization review of behavioral health services. Both commentors suggested that 
a psychotherapist's process and/or progress notes are the patient's medical 
records and that utilization review agents should have access to them. Two 
commentors strongly support the language regarding confidentiality, which 
prohibits observation of psychotherapy sessions/access to therapy notes.
Response. The department believes that confidentiality is needed because the 
therapist's notes may include information not directly relevant to the medical 
condition or treatment of the patient and may include information which is of a 
highly intimate and/or embarrassing nature. Observation of psychotherapy 
sessions by anyone other than the psychotherapist could, in all likelihood, 
impede full disclosure of medical history and problems and invade the 
psychotherapist/patient relationship. Psychotherapist's process and/or progress 
notes sometimes contain highly confidential, personal, and sometimes 
embarrassing information that is not necessary to determine medical necessity. 
The utilization review agent can use other records included in the medical 
records such as a case summary, discharge summary, lab results, history and 
physical information to determine medical necessity or appropriateness of mental 
health care. The department believes this portion of the rule will effectively 
protect a patient's privacy in such situations, while not compromising the 
utilization review agent's ability to use other pertinent records to determine 
medical necessity or appropriateness of health care. In addition, the department 
believes that this provision is consistent with the intent of the Legislature in 
Senate Bill 384. The department appreciates the comments in favor of the 
prohibition on observation of psychotherapy sessions and access to therapy 
notes. 
sec.19.1709(a). One commenter suggested adding "and patient" after "provider of 
record" in the first sentence, stating that the patient's consent for a 
utilization review agent's observing, participating in, or otherwise being 
present during a patient's examination, treatment, procedure or therapy should 
be required, not just the provider's. 
Response. The department disagrees, as the language is statutory; however, the 
physician may act on the patient's behalf as stated in sec.5.08(e) and (f) of 
the Medical Practice Act. 
sec.19.1710. One commenter suggested that the rules be revised to distinguish 
between long-term prospective referral requests and concurrent review requests, 
for which patients are entitled to a two-day determination. The commenter stated 
that in many instances utilization review agents are presented with requests for 
prospective review of referral requests made six months or even a year in 
advance. 
Response. The department disagrees, as all determinations must be made within 
the time frame required by statute. If sufficient information is not available 
at the time of the request, the utilization review agent should deny the request 
until enough information is available to make a determination.
sec.19.1710(a). One commenter suggested striking the "or" and substituting "and" 
in the last clause of sec.19.1710(a). The commenter believes that both the 
patient and the provider of record should receive the notice of adverse 
determination. 
Response. The department disagrees with the comment because the statute requires 
that only one of the named individuals be notified of the determination.
sec.sec.19.1710(b) and 19.1716(b)(7). One commenter noted there are 
typographical errors in these provisions. 
Response. The department agrees with and appreciates the comment and has changed 
the language accordingly. 
sec.19.1710(c)(2). One commenter requested clarification as to what will be 
considered adequate notice of the "clinical basis for adverse determination."
Response. The department does not agree that "clinical basis" needs to be 
further defined. Notification of adverse determinations must clearly inform the 
patient of the specific factors considered in making this particular 
determination. The term "clinical basis" is included to require an analysis of 
the patient's unique situation and to prevent a conclusory notice that the 
required treatment was not necessary. 
sec.19.1710(d)(3). One commenter requested clarification as to what is 
considered "post-stabilization care." The commenter asked whether this applies 
only to care provided in a hospital emergency or other comparable facility, and 
whether it includes inpatient care, home care, follow-up care, etc. following an 
emergency. The commenter also asked whether there is any time limitation with 
respect to what is considered post-stabilization care, e.g. whether post-
stabilization care is care rendered immediately following the stabilization of 
the emergency condition. 
Response. Post-stabilization care will be determined by the treating physician 
or health care provider at the hospital emergency facility or a comparable 
facility. The definition of emergency care primarily includes care rendered in 
an inpatient setting. Post-stabilization care can also include home care, 
follow-up care, etc. However, an HMO may require post-stabilization care to be 
performed within its network of physicians or providers. The time limitation for 
post-stabilization care is not defined but will be considered as the time 
appropriate to the circumstances related to the delivery of services and the 
condition of the patient, as determined by a physician and current medical 
practice. 
sec.19.1710(e). One commenter suggested deleting "and" and adding "or" in the 
last sentence. The commenter believes there are at least two other places in the 
rule that address notification requirements, sec.sec.19.1710(a) and 
19.1712(b)(5), but the language in these two cites uses the term "or" instead of 
"and." 
Response. The department agrees with adding "or" but not with deleting "and," 
which relates to the document that must be provided and not to the individual 
who must receive notice. The department has made the necessary changes. 
sec.19.1712. One commenter asked if an HMO's existing complaint and appeal 
process which conforms to statutory grievance and complaint rules also complies 
with the utilization review appeal procedures, or whether separate and parallel 
appeal procedure systems are required. It is the commenter's opinion that 
requiring two separate appeal processes would be confusing and very difficult to 
administer. One commenter stated that clarification should be made in the rules 
expressly authorizing utilization review agents to define and explain where and 
with whom an appeal should be filed. The commenter stated that without a formal 
filing point or designation, a utilization review agent cannot practically meet 
the processing and notification requirements of the rule, nor accrue the 
necessary reporting data outlined in sec.19.1716. One commenter stated that the 
definition of "complaint" in the utilization review rules is different from the 
definition of complaint in 25 TAC sec.sec.119.1 - 119.71. The commenter asked 
which definition governs an HMO which is also a utilization review agent. 
Response. The complaint/appeals process is intended to be one integrated 
process. The department will review the HMO laws and rules in regard to this 
matter and, if necessary, will propose changes to the HMO rules. The definition 
of "complaint" in the HMO rules specifically includes "an appeal of an adverse 
determination," as well as any enrollee dissatisfaction. The definition of 
complaint in these rules does not include appeals of an adverse determination 
because the process to respond to a denial of an adverse determination is 
already defined by the Utilization Review Act in other sections. The definition 
of complaint and an appeal of an adverse determination do not conflict and can 
be used in harmony with one another. Complaints as defined by the utilization 
review rules include all other complaints not already defined (i.e. 
administrative, qualifications of personnel, and the overall utilization review 
process). The department does not agree that clarification is needed. The appeal 
process is clearly defined in sec.19.1712. 
sec.19.1712(b). One commenter requested clarification of what constitutes a 
reasonable procedure for appeals. Another commenter stated that the department 
should clarify that subsection (b)(2) does not apply to expedited appeals, as 
the expedited appeals process time frame is resolved well before issuing the 
acknowledgment letter. A commenter stated that the rules should clarify that if 
a utilization review agent's own appeal procedures call for resolution of all 
appeals "and not just expedited appeals" in less than the five working days set 
forth in this section, then the utilization review agent is not required to send 
an acknowledgment letter or complaint form. 
Response. A "reasonable" appeals process is defined in sec.19.1712(b)(1) - (6). 
The department believes that these detailed requirements appear to adequately 
define the process. The department believes that there is no reason to change 
this provision, which is required by the statute. However, the requirement can 
be met by sending the acknowledgment and the resolution in the same letter.
sec.19.1712(b) and (c). One commenter asked if the one-page complaint form will 
be promulgated by the department or if the utilization review agent may create 
its own form, and if so, whether there are requirements for the form. One 
commenter suggested the rule list the provisions regarding appeals of adverse 
determinations. 
Response. Each utilization review agent will create its own form. The content 
requirements of the form are listed in sec.19.1712(b) and (c). However, the 
department agrees that clarification is needed and has added the appropriate 
language to subsection (b)(2). 
sec.19.1712(b)(3). One commenter suggested that the agency rewrite subsection 
(b)(3) for clarification. The commenter suggested the following language: "a 
provision that appeal decisions shall be made by a physician, or dentist, as 
appropriate. A provider may request a reconsideration of a utilization review 
decision by a specialist within 10 days of the date of notification of adverse 
determination. The provider must show good cause for the request for specialty 
review. The reconsideration will be performed by a health care provider of the 
same or similar specialty which would normally manage the service or care. 
Specialty reviews shall be completed within 15 working days of receipt of the 
request for reconsideration." 
Response. The department believes that the suggested language conflicts with the 
statutory provision and that the rule is sufficiently clear as written.
sec.19.1712(b)(4). One commenter requested clarification to as to what is 
considered "the same or similar specialty as typically manages the medical 
condition, procedure, or treatment under review." 
Response. The department believes that no clarification is needed in the rule. 
However, the following example of same or similar specialty review is provided. 
This is merely an example and same or similar specialty review may include 
situations other than the following: A newborn receives denial of days in a 
neonatal intensive care unit. The appeal would be reviewed by a neonatologist. 
sec.sec.19.1712(b)(5) and 19.1713(c). One commenter suggested that the reference 
should be to physician or health care provider "of record" as is used elsewhere 
throughout the rules. 
Response. The department agrees and has made the changes. 
sec.19.1712(c). One commenter suggested clarifying that the notice regarding an 
appealing party's right to seek review of a denial by an independent review 
organization is available only after exhausting all levels of appeals, except in 
the case of a life-threatening condition. One commenter stated that the 
requirement to notify the appealing party of the independent review organization 
process should be stayed until independent review organizations are certified 
and operational. 
Response. The department believes the rule is clear as written. However, 
clarifying language has been added to sec.19.1721(c) concerning Independent 
Review of Adverse Determinations. It is not necessary to delay notification to 
the appealing party since Article 21.58C authorizing independent review 
organizations became effective on September 1, 1997, and an independent review 
organization was certified by the department on November 5, 1997 and is 
operational. In addition, the independent review organization rules have been 
adopted by the Commissioner. 
sec.19.1713(c). One commenter stated that the department should include 
additional details as to when and in what format the written description of the 
procedures for responding to post-stabilization care should be submitted. The 
commenter asked whether the information should be resubmitted periodically.
Response. The department agrees additional language is needed concerning changes 
in the original application to clarify when documentation must be filed. The 
department has changed this section to allow for a currently licensed 
utilization review agent's amendments to the original application to be filed 
with the department for approval before March 1, 1998. Additionally, any changes 
in the procedures must be submitted not later than 30 days after the date the 
change takes effect. The procedures set forth by the Act should be submitted in 
the documentation sent to the department concerning the utilization review 
agent's phone access and can be in the utilization review agent's own format.
sec.19.1714. One commenter suggested adding a new subsection which ensures that 
the identity of a physician or specialist performing review activities not be 
considered "personal information." The commenter provided sample language. One 
commenter suggested that the rule define "personal information" to include name, 
address, telephone number, social security number and financial information, at 
a minimum. 
Response. The department does not agree that a new subsection is needed. The 
department agrees that personal information does not include physician and 
specialist names and has added clarifying language regarding such information to 
include the minimum information suggested by the commenter. 
sec.19.1716(b)(6). It is one commenter's belief that the department would 
already have information on the number of referrals to an independent review 
organization, the name of the independent review organization, and the 
disposition of the review. 
Response. The department agrees and has deleted paragraph (6) regarding the 
number of referrals, name of independent review organization and disposition of 
the review. 
sec.19.1719(a)(3). One commenter stated that additional detail should be 
included as to when and in what format HMOs must submit written documentation to 
the department. 
Response. The department agrees and has added clarification concerning when 
documentation must be submitted by an HMO, and has specified that HMOs are 
required to file documentation as outlined in sec.19.1704(c) and (d).
sec.19.1720(g). One commenter suggested the agency clarify to whom the phrase in 
subsection (g) "shall be licensed or otherwise authorized to provide . . ." 
refers. Another commenter suggested the agency clarify the last section of (h) 
by adding the term "same specialty as the provider of record." 
Response. The department does not believe that either clarification is 
necessary. This language was added to include not only licensed specialists but 
other providers that may be certified, registered, or otherwise authorized to 
practice in the United States. The language suggested by the commenter adding 
"same specialty as the provider of record" is in conflict with statutory 
language and will not be added. 
sec.19.1721. One commenter stated that this section should be stayed until the 
independent review organization certification process is developed and 
independent review organizations are certified and operational. A commenter 
suggested changing subsection (a) by inserting "for accessing independent 
review" at the end of the second sentence and changing the last sentence to 
"Such notification shall describe how to obtain independent review of such a 
determination and how the department assigns a request for review to an 
independent review organization. The notification will include the enrollee 
information form for requesting the review." 
Response. It is not necessary to delay any of the notifications since Article 
21.58C authorizing independent review organizations became effective on 
September 1, 1997, and an independent review organization was certified by the 
department on November 5, 1997 and is operational. In addition, the independent 
review organization rules have been adopted by the Commissioner. The department 
agrees with inserting "for accessing independent review" and has included the 
change. However, the department believes that the last sentence of subsection 
(a) is clear as written. 
sec.19.1721(b). One commenter suggested replacing "life-threatening" with 
"emergency" in the sentence, "The enrollee, person acting on behalf of the 
enrollee, or the enrollee's provider of record shall determine the existence of 
a life-threatening condition on the basis that a prudent layperson possessing an 
average knowledge of medicine and health would believe that his or her disease 
or condition is a life-threatening condition." One commenter suggested the 
department consider amending the proposed language regarding a medical 
determination and definition of "life-threatening." Specifically, the commenter 
suggested deleting "prudent layperson" language in this section. The commenter 
expressed concern that if a condition is considered "life-threatening," the 
enrollee can skip the internal appeal process and go directly to the independent 
review organization. It is the commenter's position that if the enrollee can 
make this determination on his or her own, it is likely that more cases will go 
to an independent review organization because they are considered "life-
threatening." Also, if a condition is considered "life-threatening" an expedited 
appeal procedure will apply which mandates the review be done by a physician who 
is of the same or similar specialty as typically manages the medical condition. 
The commenter believes more cases will have to be referred to a specialist for 
review even if the enrollee does not ask immediately for appeal to an 
independent review organization. 
Response. The department does not agree with the commenter. The definition of 
life-threatening and provisions regarding treatment of life-threatening 
conditions is statutory language. Senate Bill 386 only references life-
threatening and does not reference emergency care. The Utilization Review 
Advisory Committee was concerned that the Utilization Review Act was silent as 
to who determines whether a condition is life-threatening. Based on the 
committee's recommendation, clarification was added stating that a prudent 
layperson possessing an average knowledge of medicine and health shall make the 
determination of the presence of a life-threatening condition. The department 
recognizes that the definition may cause additional requests to an independent 
review organization without going through the utilization review appeal process 
and that more cases may have to be referred to a specialist for the appeal 
review even if the enrollee does not ask immediately for an independent review. 
However, the department agrees with the recommendation of the advisory committee 
and has added language stating "a prudent layperson possessing an average 
knowledge of medicine and health would believe that his or her disease or 
condition is a life-threatening condition." The request for an independent 
review must be sent to the utilization review agent, HMO or insurer to begin the 
independent review process. Therefore, the utilization review agent, HMO or 
insurer will have the opportunity to perform an expedited review to resolve the 
issue within three days of receipt of a request for independent review. 
sec.19.1721(c). One commenter suggested slight wording changes to the last 
sentence in this subsection. One commenter suggested modifying this subsection 
to ensure that the party has completed the internal appeal process prior to 
seeking review of the determination. It is the commenter's belief that this will 
clarify that enrollees have access to the independent review organization only 
after exhausting the internal appeal procedures. One commenter acknowledged that 
the department is trying to create a single form which can be used with all 
adverse determinations but using the term utilization review agent will confuse 
the HMO members. The commenter suggested that the form should make the name of 
the utilization review agent a variable so that the name of the HMO, health 
plan, utilization review agent, etc. can be inserted. Another commenter stated 
that there is no requirement to provide a notice explaining the enrollee's right 
to legal remedy and asks why TDI is requiring such notice to be sent to the 
enrollee. The commenter requested that the department strongly consider not 
requiring utilization review agents to provide the notice.
Response. The department agrees that clarification of subsection (c) is needed 
and has changed the language accordingly. The department agrees that using the 
term utilization review agent may confuse HMO members; accordingly, changes have 
been made to the notification form to allow the entity sending the notification 
to insert its name rather than the term "utilization review agent." The 
department agrees that there is no requirement to provide a notice explaining 
the patient's right to legal remedy; therefore, the department will not require 
such a notice. Patients will receive notification informing them of their right 
to the independent review process. 
For: National Association of Social Workers, Texas Society for Clinical Social 
Work, and The Disability Policy Consortium. For, with changes: Liberty Mutual 
Group, Blue Cross Blue Shield of Texas, Texas Medical Association, Alliance of 
American Insurers, Prudential Insurance Companies, Office of Public Insurance 
Counsel, Kaiser Foundation Health Plan of Texas, Inc., Children's Hospital 
Association of Texas, Texas Health Maintenance Organization Association, Texas 
Workers' Compensation Insurance Fund, and Harris Methodist Health Plan.
The amendments are adopted under the Insurance Code Articles 21.58A and 1.03A. 
The Insurance Code Article 21.58A provides that the commissioner may promulgate 
such reasonable rules and regulations as are necessary and proper to carry out 
the provisions of the article. In addition, it provides that the commissioner 
shall appoint an 11-member advisory committee to advise the department in 
developing such rules and regulations. The Insurance Code Article 1.03A provides 
that the Commissioner of Insurance may adopt rules and regulations to execute 
the duties and functions of the Texas Department of Insurance as authorized by 
statute. Government Code Chapter 2001, sec.sec.2001.004 et seq. authorizes and 
requires each state agency to adopt rules of practice setting forth the nature 
and requirement of available procedures and prescribes the procedures for 
adoption of rules by a state administrative agency.

sec.19.1702. Limitations on Applicability. 
(a) Except as noted in sec.19.1719 of this title (relating to Responsibility of 
HMOs and Insurers Performing Utilization Review under the Insurance Code Article 
21.58A, sec.14(g) and (h)), all utilization review agents performing utilization 
reviews of services provided or proposed to be provided to an individual within 
the state on or after June 1, 1992, regardless of where the utilization review 
activities are physically based, must comply with this subchapter. All 
regulations in this subchapter shall relate to persons or entities subject to 
this subchapter. 
(b) Insurers and HMOs are not required to obtain a certificate of registration, 
but must comply with sec.19.1719 of this title. 
(c) This subchapter does not apply to a utilization review agent or other person 
which conducts only the functions of categories of utilization review listed in 
paragraphs (1)-(3) of this subsection: 
(1) a person who provides information to enrollees about scope of coverage or 
benefits provided under a health insurance policy or health benefit plan and who 
does not determine whether particular health care services provided or to be 
provided to an enrollee are medically necessary or appropriate;
(2) a person, as defined in sec.19.1703 of this title (relating to Definitions), 
performing utilization review who is employed by, or under contract to, a 
certified utilization review agency; 
(3) a utilization review agency which conducts only the categories of 
utilization review listed in subparagraphs (A)-(E) of this paragraph:
(A) reviews performed pursuant to any contract with the federal government for 
utilization review of patients eligible for services under Title XVIII or XIX of 
the Social Security Act (42 United States Code sec.sec.1395 et seq. or 
sec.sec.1396 et seq.); 
(B) reviews performed for the Texas Medicaid Program, except reviews performed 
by a health maintenance organization that contracts with the Health and Human 
Services Commission or an agency operating part of the state Medicaid managed 
care program to provide health care services to recipients of medical assistance 
under Chapter 32, Human Resources Code; the Chronically Ill and Disabled 
Children's Services Program created pursuant to Chapter 35, Health and Safety 
Code, any program administered under Title 2, the Human Resources Code, any 
program of the Texas Department of Mental Health and Mental Retardation, or any 
program of the Texas Department of Criminal Justice; 
(C) reviews of health care services provided to patients under the authority of 
the Texas Workers' Compensation Act (Texas Civil Statutes, sec.8308-1.01 et 
seq.); 
(D) reviews of health care services provided under a policy or contract of 
automobile insurance promulgated by the department under the Insurance Code, 
Subchapter A, Chapter 5 or issued pursuant to the Insurance Code, Article 1.14; 
or 
(E) reviews that apply to the terms and benefits of the employee welfare benefit 
plans as defined in sec.3(1) of the Employee Retirement Income Security Act of 
1974 (29 U.S.C. Section 1002(1)). 

sec.19.1704. Certification of Utilization Review Agents. 
(a) An application for certification of a utilization review agent must be filed 
with the Texas Department of Insurance at the following address: Texas 
Department of Insurance, Mail Code 108-6A, P.O. Box 149104, Austin, Texas 78714-
9104. 
(b) The application must be submitted on a form which can be obtained from the 
Utilization Review Section, Mail Code 108-6A, Texas Department of Insurance, 333 
Guadalupe, P. O. Box 149104, Austin, Texas 78714-9104.
(c) The attachments to the application form require the following information: 
(1) a summary description of the utilization review plan which must include the 
matters listed in subparagraphs (A) and (B) of this paragraph. The utilization 
review plan must meet the requirements of sec.19.1705 of this title (relating to 
General Standards of Utilization Review); 
(A) an adequate summary description of screening criteria and review procedures 
to be used to determine medical necessity and appropriateness of health care; 
and 
(B) a certification, signed by an authorized representative of the company that 
screening criteria and review procedures to be applied in review determination 
are established with input from appropriate health care providers and approved 
by physicians; 
(2) copies of procedures established for appeal of an adverse determination. 
These procedures must comply with the provisions of sec.19.1712 of this title 
(relating to Adverse Determinations of Utilization Review Agents); 
(3) copies of procedures established for handling oral or written complaints by 
enrollees, patients, or health care providers. These procedures must comply with 
sec.19.1716 of this title (relating to Complaints and Information); 
(4) copies of policies and procedures which ensure that all applicable state and 
federal laws to protect the confidentiality of medical records are followed. 
These procedures must comply with sec.19.1714 of this title (relating to 
Confidentiality); 
(5) a certification signed by an authorized representative of the company that 
the utilization review agent will comply with the provisions of the Act; 
(6) a description of the categories of persons and names of the personnel 
employed or contracted to perform utilization review; 
(7) a description of the hours of operation within the State of Texas and how 
the utilization review agent may be contacted during weekends and holidays. This 
description must be in compliance with sec.19.1713 of this subchapter (relating 
to Utilization Review Agent's Telephone Access);
(8) representative samples of all materials provided by the utilization review 
agent/applicant to inform its clients, enrollees or providers of the 
requirements of the utilization review plan. Samples shall include language for 
notification of an adverse determination made in a utilization review; 
(9) a description of the basis by which the utilization review agent compensates 
its employees or agents to ensure compliance with paragraph (10) of this 
subsection; 
(10) a certification signed by an authorized representative that the utilization 
review agent shall not permit or provide compensation or anything of value to 
its employees or agents, condition employment or its employee or agent 
evaluations, or set its employee or agent performance standards, based on the 
amount or volume of adverse determinations, reductions or limitations on lengths 
of stay, benefits, services, or charges or on the number or frequency of 
telephone calls or other contacts with health care providers or patients, which 
are inconsistent with the provisions of this subchapter. 
(11) the organizational information, documents and all amendments, including: 
(A) the bylaws, rules and regulations, or any similar document regulating the 
conduct of the internal affairs of the applicant with a notarized certification 
bearing the original signature of an officer or authorized representative of the 
applicant that they are true, accurate, and complete copies of the originals; 
(B) for an applicant that is publicly held, the name of each stockholder or 
owner of more than five percent of any stock or options; 
(C) a chart showing the internal organizational structure of the applicant's 
management and administrative staff; and 
(D) a chart showing contractual arrangements of the utilization review agent. 
(12) the name and biographical information for each director, officer and 
executive of the applicant. 
(d) The utilization review agent shall report any material changes in the 
information in the application or renewal form referred to in this section, not 
later than the 30th day after the date on which the change takes effect. 
Material changes include, but are not limited to, new personnel hired who are 
officers and directors who perform utilization review; changes in the 
organizational structure; changes in contractual relationships and changes in 
the utilization review plan. 
(e) The application process is described in paragraphs (1)-(6) of this 
subsection. 
(1) The department shall have 60 days after receipt of an application to process 
the application and to certify or deny it. The department shall give the 
applicant written notice of any omissions or deficiencies noted as a result of 
the review conducted pursuant to this paragraph. 
(2) The applicant must correct the omissions or deficiencies in the application 
within 30 days of the date of the department's latest notice of such omissions 
or deficiencies. If the applicant fails to do so, the application file will be 
closed as an incomplete application. The application fee will not be refundable. 
(3) The applicant may waive any of the time limits described in this subsection, 
except in paragraph (2). The applicant may waive the time limit in paragraph (2) 
of this subsection, only with the consent of the department.
(4) The department shall maintain an application file which shall contain the 
application, notices of omissions or deficiencies, responses and any written 
materials generated by any person that was considered by the department in 
evaluating the application. 
(f) A utilization review agent must apply for renewal of the certificate of 
registration every two years from the date of certification. A renewal form must 
be used for this purpose. The renewal fee must be submitted with the renewal 
form. The renewal form can be obtained from the address listed in subsection (b) 
of this section. The completed renewal form, a summary of the current screening 
criteria, a statement signed by an authorized representative of the company 
certifying that all information previously submitted is true and correct and all 
changes have been previously filed to the application certified by the 
department, and the renewal fee must be submitted to the department at the 
address listed in subsection (a) of this section. A utilization review agent may 
continue to operate under its certificate of registration if the information and 
the fee have been filed for renewal and timely received by the department, until 
the renewal is finally denied or issued by the department. If the required 
information and fee is not received prior to the deadline for renewal of the 
certificate of registration the certificate of registration will automatically 
expire and the utilization review agent must complete and submit a new 
application form and a new fee with all required information.
(g) If an application or renewal is initially denied under this section, the 
applicant or registrant may appeal such denial under the terms of the provisions 
of Chapter 1, Subchapter A of this title (relating to Rules of Practice and 
Procedure) and Government Code, Chapter 2001 . A hearing of such appeal shall be 
conducted within 45 days of the date the petition for such hearing is filed with 
the commissioner. A decision by the commissioner shall be rendered within 60 
days of the date of the hearing. 
(h) An applicant for a certificate of registration as a utilization review agent 
must provide evidence that the applicant: 
(1) has available the services of physicians, nurses, physician's assistants, or 
other health care providers qualified to provide the service requested by the 
provider to carry out its utilization review activities in a timely manner; 
(2) meets any applicable provisions of this chapter and regulations relating to 
the qualifications of the utilization review agents or the performance of 
utilization review; 
(3) has policies and procedures which protect the confidentiality of medical 
records in accordance with applicable state and federal laws; 
(4) makes itself accessible to patients and providers 40 working hours a week 
during normal business hours in this state in each time zone in which it 
operates. 
(i) Utilization review agents that have received their certificate of 
registration prior to the adoption of these rules, must file with the department 
all changes to their original application as set forth in subsections (c) and 
(d) of this section by March 1, 1998. 

sec.19.1705. General Standards of Utilization Review.
The utilization review plan, including reconsideration and appeal requirements, 
shall be reviewed by a physician and conducted in accordance with standards 
developed with input from appropriate health care providers, including 
practicing health care providers that are both primary and specialty physicians, 
and approved by a physician. The utilization review plan shall include the 
following components: 
(1) a description of the elements of review which the utilization review agent 
provides such as: 
(A) prospective review: 
(i) hospital admission; 
(ii) procedures (such as surgical and non-surgical procedures);
(iii) courses of outpatient treatment; 
(B) second surgical opinion; 
(C) discharge planning; 
(D) concurrent review; 
(E) readmission review; and 
(F) continued stay authorization; 
(2) written procedures for: 
(A) identification of individuals with special circumstances who may require 
flexibility in the application of screening criteria through utilization review 
decisions. Special circumstances includes, but is not limited to, a person who 
has a disability, acute condition, or life-threatening illness.
(B) notification of the utilization review agent's determinations provided to 
the enrollee, a person acting on behalf of the enrollee, or the enrollee's 
provider of record as addressed in sec.19.1710 of this title (relating to Notice 
of Determinations Made by Utilization Review Agents);
(C) appeal of an adverse determination and a copy of any forms used during the 
appeal process, as required by sec.19.1711 and sec.19.1712 of this title 
(relating to Requirements Prior to Adverse Determination and Appeal of Adverse 
Determinations of Utilization Review Agents); 
(D) receiving or redirecting a toll-free normal business hour and after-hour 
calls, either in person or by recording, and assurance that a toll-free number 
will be maintained 40 hours per week during normal business hours as addressed 
in sec.19.1713 of this title (relating to Utilization Review Agent's Telephone 
Access); 
(E) review including: 
(i) any form used during the review process; 
(ii) time frames that shall be met during the review; 
(F) handling of oral or written complaints by enrollees, patients, or health 
care providers as addressed in subsection (a) of sec.19.1716 of this title 
(relating to Complaints and Information); 
(G) determining if physicians or other health care providers utilized by the 
utilization review agent are licensed, qualified, and appropriately trained; 
(H) assuring that patient-specific information obtained during the process of 
utilization review, as addressed in sec.19.1714 of this title (relating to 
Confidentiality), will be: 
(i) kept confidential in accordance with applicable federal and state laws; 
(ii) used solely for the purposes of utilization review, quality assurance, 
discharge planning, and catastrophic case management; 
(iii) shared with only those agencies (such as the claims administrator) who 
have authority to receive such information; and 
(iv) in the case of summary data, such data shall not be considered confidential 
if it does not provide sufficient information to allow identification of 
individual patients; 
(I) providing prior written notice to a physician or health care provider when 
publishing data, including quality review studies or performance tracking data 
which identifies a particular physician or health care provider;
(3) screening criteria. Each utilization review agent shall utilize written 
medically acceptable screening criteria and review procedures which are 
established and periodically evaluated and updated with appropriate involvement 
from the physicians, including practicing physicians, dentists, and other health 
care providers. Utilization review decisions shall be made in accordance with 
currently accepted medical or health care practices, taking into account special 
circumstances of each case that may require deviation from the norm stated in 
the screening criteria. Screening criteria must be objective, clinically valid, 
compatible with established principles of health care, and flexible enough to 
allow deviations from the norm when justified on a case-by-case basis. Screening 
criteria must be used to determine only whether to approve the requested 
treatment. Denials must be referred to an appropriate physician, dentist, or 
other health care provider to determine medical necessity. Such written 
screening criteria and review procedures shall be available for review and 
inspection to determine appropriateness and compliance as deemed necessary by 
the commissioner or his or her designated representative and copying as 
necessary for the commissioner to carry out his or her lawful duties under the 
Insurance Code, provided, however, that any information obtained or acquired 
under the authority of this chapter and the Act, is confidential and privileged 
and not subject to the open records law or subpoena except to the extent 
necessary for the commissioner to enforce this chapter and the Act; 
(4) delegation of review. Provide circumstances, if any, under which the 
utilization review agent may delegate the review to a hospital utilization 
review program or a health care provider. Such delegation shall not relieve the 
utilization review agent of full responsibility for compliance with this 
subchapter and the Act including the conduct of those to whom utilization review 
has been delegated. 

sec.19.1710. Notice of Determinations Made by Utilization Review Agents. 
(a) A utilization review agent shall notify the enrollee, a person acting on 
behalf of the enrollee, or the enrollee's provider of record of a determination 
made in a utilization review. 
(b) Except in the case of adverse determinations which are addressed in 
subsection (d) of this section, the notification required by this section must 
be mailed or otherwise transmitted not later than two working days after the 
date of the request for utilization review and all medical information necessary 
to substantiate the need for the treatment or service recommended is received by 
the agent. 
(c) Notification of adverse determination by the utilization review agent must 
include: 
(1) the principal reasons for the adverse determination; 
(2) the clinical basis for the adverse determination;
(3) a description or the source of the screening criteria that were utilized as 
guidelines in making the determination; 
(4) a description of the procedure for the complaint and appeal process; and 
(5) the independent review notification and the form prescribed by the 
commissioner. 
(d) The adverse determination notification must be provided:
(1) within one working day by telephone or electronic transmission to the 
provider of record in the case of a patient who is hospitalized at the time of 
the adverse determination, to be followed by a letter notifying the patient and 
the provider of record of an adverse determination within three working days; 
(2) within three working days in writing to the provider of record and the 
patient if the patient is not hospitalized at the time of the adverse 
determination; or 
(3) within the time appropriate to the circumstances relating to the delivery of 
the services and the condition of the patient, but in no case to exceed one hour 
from notification when denying post-stabilization care subsequent to emergency 
treatment as requested by a treating physician or provider. In such 
circumstances, notification shall be provided to the treating physician or 
health care provider. 
(e) For life-threatening conditions, notification of adverse determination by 
the utilization review agent must be provided within the time frames addressed 
in subsection (d) of this section. At the time of notification of the adverse 
determination, the utilization review agent shall provide to the enrollee or 
person acting on behalf of the enrollee, and the enrollee's provider of record, 
the independent review notification and the form prescribed by the commissioner.  

sec.19.1712. Appeal of Adverse Determination of Utilization Review Agents. 
(a) A utilization review agent shall maintain and make available a written 
description of appeal procedures involving an adverse determination.
(b) The procedures for appeals shall be reasonable and shall include the 
following: 
(1) a provision that an enrollee, a person acting on behalf of the enrollee, or 
the enrollee's physician or health care provider may appeal the adverse 
determination orally or in writing; 
(2) a provision that within five working days from receipt of the appeal the 
utilization review agent shall send to the appealing party a letter 
acknowledging the date of the utilization review agent's receipt of the appeal 
and include a reasonable list of documents needed to be submitted by the 
appealing party to the utilization review agent for the appeal. Such letter must 
also include provisions listed in subsections (b) and (c) of this section. When 
the utilization review agent receives an oral appeal of adverse determination, 
the utilization review agent shall send a one-page appeal form to the appealing 
party; 
(3) a provision that appeal decisions shall be made by a physician, or dentist, 
as appropriate, provided that, if the appeal is denied and within 10 working 
days the health care provider sets forth in writing good cause for having a 
particular type of a specialty provider review the case, the denial shall be 
reviewed by a health care provider in the same or similar specialty as typically 
manages the medical, dental, or specialty condition, procedure, or treatment 
under discussion for review of the adverse determination, and such specialty 
review shall be completed within 15 working days of receipt of the request; 
(4) in addition to the written appeal, a method for expedited appeal procedure 
for emergency care denials, denials of care for life-threatening conditions, and 
denials of continued stays for hospitalized patients. Such procedure shall 
include a review by a health care provider who has not previously reviewed the 
case who is of the same or a similar specialty as typically manages the medical 
condition, procedure, or treatment under review. The time in which such appeal 
must be completed shall be based on the medical or dental immediacy of the 
condition, procedure, or treatment, but may in no event exceed one working day 
from the date all information necessary to complete the appeal is received. 
(5) a provision that after the utilization review agent has sought review of the 
appeal of the adverse determination, the utilization review agent shall issue a 
response letter to the patient, a person acting on behalf of the patient, or the 
patient's physician or health care provider of record explaining the resolution 
of the appeal. Such letter shall include:
(A) a statement of the specific medical, dental, or contractual reasons for the 
resolution; 
(B) the clinical basis for such decision; 
(C) the specialization of any physician or other provider consulted; and 
(D) notice of the appealing party's right to seek review of the denial by an 
independent review organization and the procedures for obtaining that review. 
(6) written notification to the appealing party of the determination of the 
appeal, as soon as practical, but in no case later than 30 days after the date 
the utilization review agent receives the appeal.
(c) In a circumstance involving an enrollee's life-threatening condition, the 
enrollee is entitled to an immediate appeal to an independent review 
organization and is not required to comply with procedures for an internal 
review of the utilization review agent's adverse determination. 

sec.19.1713. Utilization Review Agent's Telephone Access. 
(a) A utilization review agent shall have appropriate personnel reasonably 
available by toll-free telephone at least 40 hours per week during normal 
business hours in both time zones in Texas, if applicable, to discuss patients' 
care and allow response to telephone review requests. 
(b) A utilization review agent must have a telephone system capable of accepting 
or recording or providing instructions to incoming calls during other than 
normal business hours and shall respond to such calls not later than two working 
days of the later of the date on which the call was received or the date the 
details necessary to respond have been received from the caller. 
(c) A utilization review agent must provide a written description to the 
commissioner setting forth the procedures to be used when responding to post-
stabilization care subsequent to emergency treatment as requested by a treating 
physician or health care provider of record. 

sec.19.1714. Confidentiality. 
(a) A utilization review agent shall preserve the confidentiality of individual 
medical records to the extent required by law. 
(b) A utilization review agent may not disclose or publish individual medical 
records, personal information, or other confidential information about a patient 
obtained in the performance of utilization review without the prior written 
consent of the patient or as otherwise required by law. Personal information 
shall include at a minimum, name, address, phone number, social security number, 
and financial information. If such authorization is submitted by anyone other 
than the individual who is the subject of the personal or confidential 
information requested, such authorization must: 
(1) be dated; and 
(2) contain the signature of the individual who is the subject of the personal 
or confidential information requested. The signature must have been obtained one 
year or less prior to the date the disclosure is sought or the authorization is 
invalid. 
(c) A utilization review agent may provide confidential information to a third 
party under contract or affiliated with the utilization review agent for the 
sole purpose of performing or assisting with utilization review. Information 
provided to third parties shall remain confidential. 
(d) If an individual submits a written request to the utilization review agent 
for access to recorded personal information about the individual, the 
utilization review agent shall within 10 business days from the date such 
request is received: 
(1) inform the individual submitting the request of the nature and substance of 
the recorded personal information in writing; and 
(2) permit the individual to see and copy, in person, the recorded personal 
information pertaining to the individual or to obtain a copy of the recorded 
personal information by mail, at the discretion of the individual, unless the 
recorded personal information is in coded form, in which case an accurate 
translation in plain language shall be provided in writing. 
(e) A utilization review agent's charges for providing a copy of recorded 
personal information to individuals shall not exceed ten cents per page and may 
not include any costs that are otherwise recouped as part of the charge for 
utilization review. 
(f) The utilization review agent may not publish data which identifies a 
particular physician or health care provider, including any quality review 
studies or performance tracking data without prior written notice to the 
involved health care provider. This prohibition does not apply to internal 
systems or reports used by the utilization review agent. 
(g) Documents in the custody of the utilization review agent that contain 
confidential patient information or physician or health care provider financial 
data shall be destroyed by a method which induces complete destruction of the 
information when the agent determines the information is no longer needed. 
(h) All patient, physician, and health care provider data shall be maintained by 
the utilization review agent in a confidential manner which prevents 
unauthorized disclosure to third parties. Nothing in this article shall be 
construed to allow a utilization review agent to take actions that violate a 
state or federal statute or regulation concerning confidentiality of patient 
records. 
(i) To assure confidentiality, a utilization review agent must, when contacting 
a physician's office or hospital, provide its certification number, the caller's 
name, and professional qualifications to the provider's named utilization review 
representative in the health care provider's office.
(j) Upon request by the provider, the utilization review agent shall present 
written documentation that it is acting as an agent of the payor for the 
relevant patient. 
(k) The utilization review agent's procedures shall specify that specific 
information exchanged for the purpose of conducting reviews will be considered 
confidential, be used by the private review agent solely for the purposes of 
utilization review, and shared by the utilization review agent with only those 
third parties who have authority to receive such information, such as the claim 
administrator. The utilization review agent's process shall specify that 
procedures are in place to assure confidentiality and that the utilization 
review agent agrees to abide by any federal and state laws governing the issue 
of confidentiality. Summary data which does not provide sufficient information 
to allow identification of individual patients or providers need not be 
considered confidential. 
(l) Medical records and patient specific information shall be maintained by the 
utilization review agent in a secure area with access limited to essential 
personnel only. 
(m) Information generated and obtained by the utilization review agents in the 
course of utilization review shall be retained for at least two years if the 
information relates to a case for which an adverse decision was made at any 
point or if the information relates to a case which may be reopened. 
(n) Notwithstanding the provisions in subsections (a) - (m) of this section, the 
utilization review agent shall provide to the commissioner on request individual 
medical records or other confidential information for determination of 
compliance with this subchapter. The information is confidential and privileged 
and is not subject to the open records law, Government Code, Chapter 552, or to 
subpoena, except to the extent necessary to enable the commissioner to enforce 
this subchapter.  

sec.19.1716. Complaints and Information. 
(a) Utilization review agent's complaint system. A utilization review agent 
shall establish and maintain a complaint system that provides reasonable 
procedures for the resolution of oral or written complaints initiated by 
enrollees, patients, or health care providers concerning the utilization review 
and shall maintain records of such complaints for three years from the time the 
complaints are filed. The complaint procedure shall include a written response 
to the complainant by the agent within 30 days. 
(b) Utilization review agent's reporting requirements to the department. By 
March 1, of each year, the utilization review agent shall submit to the 
commissioner or his or her delegated representative, a summary report of all 
complaints at such times and in such form as the commissioner may require and 
shall permit the commissioner to examine the complaints and all relevant 
documents at any time. The summary report covers reviews performed by the 
utilization review agent during the preceding calendar year and includes:
(1) the total number of written notices of adverse determinations;
(2) a listing of appeals of adverse determinations, by the medical condition 
that is the source of the dispute using primary ICD-9 (physical diagnosis) or 
DSM-IV (mental health diagnosis) code, and by the treatment in dispute, if any, 
using CPT (procedure) code or other relevant procedure code if a CPT designation 
is not available, or any other nationally recognized numerically codified 
diagnosis or procedure;
(3) the classification of appellant (i.e., health care provider, enrollee, 
patient, etc.); 
(4) the subject matter of the appeal of the adverse determination. Appeal of 
adverse determinations shall be categorized as follows: 
(A) benefit denial or limitation (e.g., treatment not pre-authorized, treatment 
not medically necessary, hospital stay not medically necessary, referral to 
specialty physician not provided); 
(B) timely determinations (e.g., utilization review agent not responding to 
requests in a timely manner, appropriate personnel not available by telephone); 
(C) screening criteria; 
(5) the disposition of the appeal of adverse determination (either in favor of 
the appellant, or in favor of the original utilization review determination) at 
each level of the notification and appeal process;
(6) the subject matter of the complaint. Complaints shall be categorized as 
follows: 
(A) administration (e.g., copies of medical records not paid for, too many calls 
or written requests for information from provider, too much information 
requested from provider); 
(B) qualifications of utilization review agent's personnel;
(C) appeal/complaint process (e.g., treating physician unable to discuss plan of 
treatment with utilization review physician, no notice of adverse determination, 
no notice of clinical basis for adverse determination, written procedures for 
appeal not provided). 
(c) Complaints to the department. Within a reasonable time period, upon receipt 
of a written complaint alleging a violation of this subchapter or the Act, by a 
utilization review agent, from an enrollee's health care provider, a person 
acting on behalf of the enrollee, or the enrollee, the commissioner or his or 
her delegated representative shall investigate the complaint, notify the 
utilization review agent of the complaint, require response by the utilization 
review agent addressing the complaint within 10 days of receipt of the 
complaint, and furnish a written response to the complainant and the utilization 
review agent named. The response will not identify in any manner, the patient or 
patients, without written consent. This response must include the following: 
(1) a statement of the original complaint; 
(2) a copy of any written response by the utilization review agent. The written 
response should not contain privileged medical records. If it is necessary to 
refer to medical records, they shall be separately forwarded with the response 
and clearly marked as privileged medical records; 
(3) a statement of the findings of the commissioner or his or her delegated 
representative and an explanation of the basis of such findings; 
(4) corrective actions, if any, on the part of the utilization review agent 
which the commissioner or his or her designated representative finds appropriate 
and whether the utilization review agent has voluntarily agreed to take such 
action; 
(5) a time frame in which any corrective actions should be completed. 
(d) Evidence of corrective action. The utilization review agent will provide 
evidence of corrective action within the specified time frame to the 
commissioner or his or her representative. 
(e) Authority of the department to make inquiries. In addition to the authority 
of the commissioner to respond to complaints described in subsection (b) of this 
section, the department is authorized to address inquiries to any utilization 
review agent in relation to the agents' business condition or any matter 
connected with its transactions which the department may deem necessary for the 
public good or for a proper discharge of its duties. It shall be the duty of the 
agent to promptly answer such inquiries in writing.
(f) Lists of utilization review agents. The commissioner shall maintain and 
update monthly a list of utilization review agents issued certificates and the 
renewal date for those certificates. The commissioner shall provide the list at 
cost to all individuals or organizations requesting the list.
(g) On-site review by the Texas Department of Insurance.
(1) The commissioner or the commissioner's designated representative is 
authorized to make a complete on-site review of the operations of each 
utilization review agent at the principal place of business for such agent, as 
often as is deemed necessary. 
(2) Utilization review agents will be notified of the scheduled on-site visit by 
letter, which will specify, at a minimum, the identity of the commissioner's 
designated representative and the expected arrival date and time.
(3) The utilization review agent must make available during such on-site visits 
all records relating to its operation. 
(4) The commissioner or the designated representative may perform periodic 
telephone audits of utilization review agents authorized to conduct business in 
this state, to determine if the agents are reasonably accessible.  

sec.19.1719. Responsibility of HMOs and Insurers Performing Utilization Review 
Under the Insurance Code, Article 21.58A, sec.14, (g) and (h). 
(a) HMOs performing utilization review. 
(1) HMOs performing utilization review under the Insurance Code, Article 21.58A, 
sec.14(g) shall be subject to sec.19.1701 of this title (relating to General 
Provisions), sec.19.1702 of this title (relating to Limitations on 
Applicability), sec.19.1703 of this title (relating to Definitions), 
sec.19.1704(c) and (d) of this title (relating to Certification of Utilization 
Review Agents), sec.19.1705 of this title (relating to General Standards of 
Utilization Review), sec.19.1706 of this title (relating to Personnel), 
sec.19.1707 of this title (relating to Prohibitions of Certain Activities of 
Utilization Review Agents), sec.19.1708 of this title (relating to Utilization 
Review Agent Contact with and Receipt of Information from Health Care 
Providers), sec.19.1709 of this title (relating to On-Site Review by the 
Utilization Review Agent), sec.19.1710 of this title (relating to Notice of 
Determinations Made by Utilization Review Agents), sec.19.1711 of this title 
(relating to Requirements Prior to Adverse Determination), sec.19.1712 of this 
title (relating to Appeal of Adverse Determination of Utilization Review 
Agents), sec.19.1713 of this title (relating to Utilization Review Agent's 
Telephone Access), sec.19.1714 of this title (relating to Confidentiality), 
sec.19.1715 of this title (relating to Retrospective Review of Medical 
Necessity), sec.19.1716 of this title (relating to Complaints and Information), 
sec.19.1717 of this title (relating to Administrative Violations), sec.19.1720 
of this title (relating to Specialty Utilization Review Agent), and sec.19.1721 
of this title (relating to Independent Review of Adverse Determinations) with 
respect to their operations under the provisions of the Act, sec.14(g).
(2) When a health maintenance organization performs utilization review for a 
person or entity subject to this subchapter other than one for which it is the 
payor, such health maintenance organization shall be required to obtain a 
certificate under the Act, sec.3, and comply with all the provisions of the Act 
(3) Health maintenance organizations performing utilization review under the 
Act, sec.14(g) must register with the department and submit written 
documentation demonstrating compliance with all filing requirements defined in 
sec.19.1704(c) and (d) of this title (relating to Certification of Utilization 
Review Agents) and the name, address, contact name and phone number of the 
health maintenance organization. 
(4) A health maintenance organization, including a health maintenance 
organization that contracts with the Health and Human Services Commission or an 
agency operating part of the state Medicaid managed care program to provide 
health care services to recipients of medical assistance under Chapter 32, Human 
Resources Code, is subject to this article. 
(5) Health maintenance organizations must submit to assessment of maintenance 
taxes under the Insurance Code Article 20A.33, to cover the costs of 
administering compliance of health maintenance organizations under the Act. 
(b) Insurers performing utilization review. 
(1) An insurer that delivers or issues for delivery a health insurance policy in 
Texas is subject to the Insurance Code Article 21.58A and such insurer shall be 
subject to assessment of maintenance tax under the Insurance Code to cover the 
costs of administering compliance of insurers.
(2) Insurers performing utilization review under the Insurance Code, Article 
21.58A, sec.14 (g) will be subject to sec.19.1701 of this title (relating to 
General Provisions), sec.19.1702 of this title (relating to Limitations on 
Applicability), sec.19.1703 of this title (relating to Definitions), 
sec.19.1704(c) and (d) of this title (relating to Certification of Utilization 
Review Agents), sec.19.1705 of this title (relating to General Standards of 
Utilization Review), sec.19.1706 of this title (relating to Personnel), 
sec.19.1707 of this title (relating to Prohibitions of Certain Activities of 
Utilization Review Agents), sec.19.1708 of this title (relating to Utilization 
Review Agent Contact with and Receipt of Information from Health Care 
Providers), sec.19.1709 of this title (relating to On-Site Review by the 
Utilization Review Agent), sec.19.1710 of this title (relating to Notice of 
Determinations Made by Utilization Review Agents), sec.19.1711 of this title 
(relating to Requirements Prior to Adverse Determination), sec.19.1712 of this 
title (relating to Appeal of Adverse Determination of Utilization Review 
Agents), sec.19.1713 of this title (relating to Utilization Review Agent's 
Telephone Access), sec.19.1714 of this title (relating to Confidentiality), 
sec.19.1715 of this title (relating to Retrospective Review of Medical 
Necessity), sec.19.1716 of this title (relating to Complaint and Information), 
sec.19.1717 of this title (relating to Administrative Violations), sec.19.1720 
of this title (relating to Specialty Utilization Review Agent), and sec.19.1721 
of this title (relating to Independent Review of Adverse Determinations) with 
respect to their operations under the provisions of the Act, sec.14(h).
(3) When an insurer performs utilization review for a person or entity subject 
to this subchapter other than one for which it is the payor, such insurer shall 
be required to obtain a certificate under the Act, sec.3, and comply with all 
the provisions of the Act. 
(4) Insurers performing utilization review under the Act, sec.14(h) must 
register with the department and submit written documentation demonstrating 
compliance with all the filing requirements defined in sec.19.1704(c) and (d) of 
this title (relating to Certification of Utilization Review Agents) and the 
name, address, contact name and phone number of the insurer. 

sec.19.1721. Independent Review of Adverse Determinations.
(a) For life-threatening conditions, notification of adverse determination by 
the utilization review agent must be provided within the time frames addressed 
in sec.19.1710(d) of this title (relating to Notice of Determinations Made by 
Utilization Review Agents). At the time of notification of the adverse 
determination, the utilization review agent shall provide to the enrollee, or 
person acting on behalf of the enrollee, and the enrollee's provider of record, 
the notification and the form prescribed by the commissioner for accessing 
independent review. Such notification shall describe how to obtain independent 
review of such determination and how the department assigns a request for review 
to an independent review organization, and include the form requesting enrollee 
information. 
(b) The enrollee, person acting on behalf of the enrollee, or the enrollee's 
provider of record shall determine the existence of a life-threatening condition 
on the basis that a prudent layperson possessing an average knowledge of 
medicine and health would believe that his or her disease or condition is a 
life-threatening condition.
(c) A utilization review agent shall permit any party who has completed the 
internal appeals process as defined in Insurance Code Article 21.58A sec.6 and 
such appeal of an adverse determination resulted in a denial by the utilization 
review agent, health maintenance organization or insurer, to seek review of that 
determination by an independent review organization assigned to the appeal in 
accordance with Insurance Code Article 21.58C as follows: 
(1) the utilization review agent shall provide a notification prescribed by the 
commissioner to the enrollee or the person acting on behalf of the enrollee and 
the enrollee's provider of record, on how to appeal the denial of an internal 
appeal to an independent review organization. The notification shall describe 
how to obtain independent review of such determination and how the department 
assigns a request for review to an independent review organization, and include 
the form requesting enrollee information. 
(2) the utilization review agent shall provide the notification and the form 
prescribed by the commissioner to the enrollee or the person acting on behalf of 
the enrollee and the enrollee's provider of record at the time of denial of the 
appeal; 
(3) the form prescribed by the commissioner shall be completed by the enrollee, 
person acting on behalf of the enrollee or the enrollee's provider of record and 
returned to the utilization review agent to begin the independent review 
process. The form prescribed by the commissioner authorizing release of medical 
information to the independent review organization must be signed by the 
enrollee or the enrollee's legal guardian. 
(d) The utilization review agent shall notify the department upon receipt of the 
request for an independent review. 
(e) The utilization review agent shall provide information contained in the form 
prescribed by the commissioner to the department. The notification and 
information shall be submitted via modem or, in the event that modem is 
unavailable, through facsimile. 
(f) The utilization review agent may access the department on working days, 
between 7 AM and 6 PM Central time, Monday through Friday, to obtain assignment 
of an independent review organization. 
(g) The department shall, within one working day of receipt of the request, 
randomly assign an independent review organization and notify the utilization 
review agent and the independent review organization of the assignment. The 
department shall send notification to the enrollee or person acting on behalf of 
the enrollee and the enrollee's provider of record no later than one working day 
after the assignment has been made. 
(h) Not later than the third working day after the date that the utilization 
review agent receives a request for review, the utilization review agent shall 
provide to the assigned independent review organization a copy of: 
(1) any medical records of the enrollee in the possession of the utilization 
review agent that are relevant to the review; 
(2) any documents used by the plan in making the determinations to be reviewed 
by the organization; 
(3) the written notification described by sec.19.1712(b)(6) of this title 
(relating to Appeal of Adverse Determination of Utilization Review Agents); 
(4) any documentation and written information submitted to the utilization 
review agent in support of the appeal; and 
(5) a list containing the name, address and phone number of each physician or 
health care provider who has provided care to the enrollee and who may have 
medical records relevant to the appeal. 
(i) The utilization review agent shall comply with the independent review 
organization's determination with respect to the medical necessity or 
appropriateness of health care items and services for an enrollee. 
(j) The utilization review agent shall pay for the independent review. 
(k) The utilization review agent may recover costs associated with the 
independent review from the payor.  
This agency hereby certifies that the adoption has been reviewed by legal 
counsel and found to be a valid exercise of the agency's legal authority.
Issued in Austin, Texas, on December 1, 1997.
TRD-9716037
Caroline Scott
General Counsel and Chief Clerk
Texas Department of Insurance
Effective date: December 22, 1997
Proposal publication date: September 5, 1997
For further information, please call: (512) 463-6327

TITLE 31. NATURAL RESOURCES AND CONSERVATION
PART II. Texas Parks and Wildlife Department
CHAPTER 69.Resource Protection
Issuance of Marl, Sand and Gravel Permits
31 TAC sec.sec.69.110, 69.114
The Texas Parks and Wildlife Commission, in a regularly scheduled public hearing 
on November 6, 1997, adopts amendments of sec.69.110 and sec.69.114, concerning 
rules for issuance of Marl, Sand and Gravel Permits without changes as published 
in the Texas Register on October 3, 1997 (22 TexReg 9859).
Parks and Wildlife Code sec.86.006 and sec.86.020 authorizes the Commission to 
establish terms and conditions of permits it issues for marl, sand and gravel 
removal. 
The rule amendments are needed in order to reduce unnecessary costs to permit 
holders in the application for new permits and renewals of existing permits. The 
rule amendments are also necessary to provide a source of continuing revenue to 
the Department in order to provide for orderly administration and enforcement of 
the rules.
The Department received no comments in opposition to the proposed amendments. A 
total of two letters were received commenting on the proposed amendments. One 
letter was from a representative of CSB Asphalt, Inc. And the other was from a 
representative of Sand Supply, Inc. Both commentors supported the proposal. The 
Department agrees with the commentors that the rule amendments are needed. The 
proposed amendments increase the valid life of a marl, sand and gravel permit 
from the current one-year to a new three-years. Permits may be renewed at the 
end of the three-year period for an additional three-year period. Application, 
review and renewal fees have also been doubled in order to continue to provide 
revenue for monitoring and enforcement activities on permits. To permit holders, 
the principal costs of obtaining a permit are in the preparation of the 
application. The application process is complex enough to require up to one 
year's worth of preparation time to prepare before filing. Thus, some 
applicants, after receiving a one-year permit, must immediately begin preparing 
a renewal application for the next year. The proposed amendments will reduce the 
costs to permit holders by reducing the number of times they must prepare 
renewal applications. The increased fees will offset the loss of public fee 
revenue used for monitoring permit holders performance.
Because the subject of the proposed amendments is in all cases public property 
and no restrictions are imposed by the regulations on the use of private 
property, there is no takings impact within the purview of the private Real 
Property Rights Preservation Act, (the Act) Chapter 2007 of the Government Code. 
Furthermore, there are no governmental actions allowed by the proposed 
regulations which fall under the purview of the definition of a "taking" in 
sec.2007.002(5) of the Act.
The amendments are adopted under Parks and Wildlife Code sec.86.006 and 
sec.86.020 which authorize the Commission to establish rules for the terms and 
conditions of permits to remove marl, sand and gravel. Chapter 86 of the Parks 
and Wildlife Code authorizes the Commission to manage the marl, sand and gravel 
in state owned riverbeds. 
This agency hereby certifies that the adoption has been reviewed by legal 
counsel and found to be a valid exercise of the agency's legal authority. 
Issued in Austin, Texas, on November 24, 1997.
TRD-9715831
Bill Harvey
Regulatory Coordinator
Texas Parks and Wildlife Department 
Effective date: December 15, 1997
Proposal publication date: October 3, 1997
For further information, please call: (512) 389-4642