State Law

Texas Statutes-Insurance Code-Title 14-Chapter 4201- Subchapter H. Appeal of Adverse Determinations

08/24/2023 Texas Section 4201.359

Notice of Appeal

State Medical Necessity Appeals-Deadlines

(a) The procedures for appealing an adverse determination must require written notice to the appealing party of the determination of the appeal as soon as practicable, but not later than the 30th calendar day, after the date the utilization review agent receives the appeal.

(b) If the appeal is denied, the notice must include a clear and concise statement of:

(1) the clinical basis for the denial;

(2) the specialty of the physician or other health care provider making the denial; and

(3) the appealing party’s right to seek review of the denial by an independent review organization under Subchapter I and the procedures for obtaining that review.