28 TAC § 19.1702. Applicability, DIVISION 1. UTILIZATION REVIEWS
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Texas Administrative Code › Title 28 INSURANCE › Part 1 TEXAS DEPARTMENT OF INSURANCE › Chapter 19 LICENSING AND REGULATION OF INSURANCE PROFESSIONALS › 28 TAC § 19.1702
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(a) Limitations on applicability. Except as provided in Insurance Code Chapter 4201, this subchapter applies to utilization review performed under a health benefit plan or a health insurance policy.
(1) This subchapter does not apply to utilization review performed under workers' compensation insurance coverage.
(2) This subchapter does not apply to a person who provides information to an enrollee; an individual acting on behalf of an enrollee; or an enrollee's physician, doctor, or other health care provider about scope of coverage or benefits, and does not determine the medical necessity, appropriateness, or the experimental or investigational nature of health care services.
(b) Applicability of other law. In addition to the requirements of this subchapter, provisions of Insurance Code Chapter 843, concerning Health Maintenance Organizations; Insurance Code Chapter 1222, concerning Preauthorization for Medical or Health Care Service; Insurance Code Chapter 1301, concerning Preferred Provider Benefit Plans; Insurance Code Chapter 1352, concerning Brain Injury; Insurance Code Chapter 1369, concerning Benefits Related to Prescription Drugs and Devices and Related Services; and Insurance Code Chapter 1451, Subchapter E, concerning Dental Care Benefits in Health Insurance Policies or Employee Benefit Plans, apply to this subchapter.
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