State Law

Texas Admin. Code-Title 28-Part 1-Chapter 19-Subchapter R. Utilization Reviews for Health Care Provided under a Health Benefit Plan or Health Insurance Policy

08/24/2023 Texas Section 19.705

General Standards of Utilization Review

U.R. Criteria

See bold text below:

(a) Review of utilization review plan. The utilization review plan must be reviewed and approved by a
physician licensed to practice medicine in Texas and conducted under standards developed and periodically
updated with input from both primary and specialty physicians, doctors, and other health care providers, as

(b) Special circumstances.

(1) A utilization review determination must be made in a manner that takes into account special circumstances of the case that may require deviation from the norm stated in the screening criteria or relevant guidelines. Special circumstances include, but are not limited to, an individual who has a disability, acute condition, or life-threatening illness.

(2) If coverage is available for stage-four advanced, metastatic cancer and associated conditions, as defined
by Insurance Code §1369.211, the URA cannot require, before coverage of a prescription drug, that the

(A) fail to successfully respond to a different drug; or

(B) prove a history of failure of a different drug.

(3) Paragraph (2) of this subsection only applies to a drug the use of which is:

(A) consistent with best practices for the treatment of stage-four advanced, metastatic cancer or an associated condition, as defined by Insurance Code §1369.211;

(B) supported by peer-reviewed, evidence-based literature; and

(C)approved by the United States Food and Drug Administration.

U.R. Criteria

(c) Screening criteria. Each URA must utilize written screening criteria that are evidence based, scientifically valid, outcome focused, and that comply with the requirements in Insurance Code §4201.153. The screening criteria must also recognize that if evidence-based medicine is not available for a particular health care service provided, the URA must utilize generally accepted standards of medical practice recognized in the medical community.

(d) Referral and determination of adverse determinations. Adverse determinations must be referred to and
may only be determined by an appropriate physician, doctor, or other health care provider with appropriate
credentials under §19.1706 of this title (relating to Requirements and Prohibitions Relating to Personnel) to
determine the medical necessity, the appropriateness, or the experimental or investigational nature of health
care services.

(e)Delegation of review. A URA, including a specialty URA, may delegate the utilization review to
qualified personnel in a hospital or other health care facility in which the health care services to be reviewed
were, or are, to be provided. The delegation does not relieve the URA of full responsibility for compliance
with this subchapter and Insurance Code Chapter 4201, including the conduct of those to whom utilization
review has been delegated.

(f) Complaint system. The URA must develop and implement procedures for the resolution of oral or written
complaints initiated by enrollees, individuals acting on behalf of the enrollee, or health care providers
concerning the utilization review. The URA must maintain records of complaints for three years from the
date the complaints are filed. The complaints procedure must include a requirement for a written response to
the complainant by the agent within 30 calendar days. The written response must include TDI’s address,
toll-free telephone number, and a statement explaining that a complainant is entitled to file a complaint with
TDI. The agency certifies that legal counsel has reviewed the adoption and found it to be a valid exercise of the
agency’s legal authority.