Tex. Ins. Code § 4201.153 · Subchapter D. UTILIZATION REVIEW: GENERAL STANDARDS
SCREENING CRITERIA AND REVIEW PROCEDURES.
Text — Current through the 89th 2nd Called Legislative Session, 2025
(a) A utilization review agent shall use written medically acceptable screening criteria and review procedures that are established and periodically evaluated and updated with appropriate involvement from physicians, including practicing physicians, dentists, and other health care providers.
(b) A utilization review determination shall be made in accordance with currently accepted medical or health care practices, taking into account special circumstances of the case that may require deviation from the norm stated in the screening criteria.
(c) Screening criteria must be:
(1) objective;
(2) clinically valid;
(3) compatible with established principles of health care; and
(4) flexible enough to allow a deviation from the norm when justified on a case-by-case basis.
(d) Screening criteria must be used to determine only whether to approve the requested treatment. A denial of requested treatment must be referred to an appropriate physician, dentist, or other health care provider to determine medical necessity.
Notes and commentary — not statutory text
History
Added by Acts 2005, 79th Leg., Ch. 727 (H.B. 2017), Sec. 4, eff. April 1, 2007.
Source of truth
- Edition
- Current through the 89th 2nd Called Legislative Session, 2025
- Official file
- https://statutes.capitol.texas.gov/Docs/IN/htm/IN.4201.htm
- Text hash
- sha256 7e905661e9e1eca060a1d12a1028850d9783e2f3182d1d3ee780b70b4f1f0e15
- Composed by
- compose_tx.py 2026-10-05: the Legislative Council's chapter files read in document order; verify_tx.py's independent reading (lxml DOM walk) agrees character for character
Cited by 1 provision
Provisions in this library whose text cites Tex. Ins. Code § 4201.153. Each shows the citation as that text prints it.
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