State Law

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

08/24/2023 Texas Section 4201.356

Decision by Physician Required; Specialty Review

State Medical Necessity Appeals-Deadlines

(a) The procedures for appealing an adverse determination must provide that a physician licensed to practice medicine makes the decision on the appeal, except as provided by Subsection (b).

(b) If not later than the 10th working day after the date an appeal is requested or denied the enrollee’s health care provider requests a particular type of specialty provider review the case, a health care provider who is of the same or a similar specialty as the health care provider who would typically manage the medical or dental condition, procedure, or treatment under consideration for review shall review the denial or the decision denying the appeal. The specialty review must be completed within 15 working days of the date the health care provider’s request for specialty review is received.