28 Tex. Admin. Code § 19.1702 - Applicability
(a) Limitations on applicability. Except as
provided in Insurance Code Chapter 4201, this subchapter applies to utilization
review performed under a health benefit plan or a health insurance policy.
(1) This subchapter does not apply to
utilization review performed under workers' compensation insurance
coverage.
(2) This subchapter does
not apply to a person who provides information to an enrollee; an individual
acting on behalf of an enrollee; or an enrollee's physician, doctor, or other
health care provider about scope of coverage or benefits, and does not
determine the medical necessity, appropriateness, or the experimental or
investigational nature of health care services.
(b) Applicability of other law. In addition
to the requirements of this subchapter, provisions of Insurance Code Chapter
843, concerning Health Maintenance Organizations; Insurance Code Chapter 1222,
concerning Preauthorization for Medical or Health Care Service; Insurance Code
Chapter 1301, concerning Preferred Provider Benefit Plans; Insurance Code
Chapter 1352, concerning Brain Injury; Insurance Code Chapter 1369, concerning
Benefits Related to Prescription Drugs and Devices and Related Services; and
Insurance Code Chapter 1451, Subchapter E, concerning Dental Care Benefits in
Health Insurance Policies or Employee Benefit Plans, apply to this
subchapter.
Notes
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