Tex. Ins. Code § 4201.357 · Subchapter H. APPEAL OF ADVERSE DETERMINATION
EXPEDITED APPEAL FOR DENIAL OF EMERGENCY CARE, CONTINUED HOSPITALIZATION, PRESCRIPTION DRUGS OR INTRAVENOUS INFUSIONS.
Text — Current through the 89th 2nd Called Legislative Session, 2025
(a) The procedures for appealing an adverse determination must include, in addition to the written appeal, a procedure for an expedited appeal of a denial of emergency care, a denial of continued hospitalization, or a denial of another service if the requesting health care provider includes a written statement with supporting documentation that the service is necessary to treat a life-threatening condition or prevent serious harm to the patient. That procedure must include a review by a health care provider who:
(1) has not previously reviewed the case; and
(2) 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 review in the appeal.
(a-1) The procedures for appealing an adverse determination must include, in addition to the written appeal and the appeal described by Subsection (a), a procedure for an expedited appeal of a denial of prescription drugs or intravenous infusions for which the patient is receiving benefits under the health insurance policy. That procedure must include a review by a health care provider who:
(1) has not previously reviewed the case; and
(2) 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 review in the appeal.
(a-2) An adverse determination under Section 1369.0546 is entitled to an expedited appeal. The physician or, if appropriate, other health care provider deciding the appeal must consider atypical diagnoses and the needs of atypical patient populations.
(b) The time for resolution of an expedited appeal under this section shall be based on the medical or dental immediacy of the condition, procedure, or treatment under review, provided that the resolution of the appeal may not exceed one working day from the date all information necessary to complete the appeal is received.
Notes and commentary — not statutory text
History
Added by Acts 2005, 79th Leg., Ch. 727 (H.B. 2017), Sec. 4, eff. April 1, 2007.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 1037 (H.B. 1621), Sec. 5, eff. September 1, 2015.
Acts 2015, 84th Leg., R.S., Ch. 1037 (H.B. 1621), Sec. 6, eff. September 1, 2015.
Acts 2017, 85th Leg., R.S., Ch. 103 (S.B. 680), Sec. 3, eff. September 1, 2017.
Acts 2019, 86th Leg., R.S., Ch. 1218 (S.B. 1742), Sec. 3.06, eff. September 1, 2019.
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 55c86fcd344efdf9640177d25a43ebfa45027198e76358ed81741226b683522d
- 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
This section cites
Provisions in this library that the text above cites, as it prints each citation. A range cited as “ss. 61.13-61.16” links its first and last provisions.
Cited by 4 provisions
Provisions in this library whose text cites Tex. Ins. Code § 4201.357. Each shows the citation as that text prints it.
Insurance Code
- Tex. Ins. Code § 843.3483REMEDY FOR NONCOMPLIANCE.Printed as Section 4201.357
- Tex. Ins. Code § 1301.1353REMEDY FOR NONCOMPLIANCE.Printed as Section 4201.357
- Tex. Ins. Code § 4201.053MEDICAID AND OTHER STATE HEALTH OR MENTAL HEALTH PROGRAMS.Printed as Sections 4201.303(c), 4201.304(b), 4201.357
- Tex. Ins. Code § 4201.054WORKERS' COMPENSATION BENEFITS.Printed as Sections 4201.303(c), 4201.304(b), 4201.357
Procedural information only. Not legal advice and not a substitute for the advice of an attorney. Confirm the current text with the official publisher before relying on it.