Texas Administrative Code
Title 28 - INSURANCE
Part 1 - TEXAS DEPARTMENT OF INSURANCE
Chapter 19 - LICENSING AND REGULATION OF INSURANCE PROFESSIONALS
Subchapter R - UTILIZATION REVIEWS FOR HEALTH CARE PROVIDED UNDER A HEALTH BENEFIT PLAN OR HEALTH INSURANCE POLICY
Division 1 - UTILIZATION REVIEWS
Section 19.1713 - Confidentiality
Universal Citation: 28 TX Admin Code § 19.1713
Current through Reg. 50, No. 13; March 28, 2025
(a) Confidentiality requirements. To ensure confidentiality, a URA must, when contacting a physician's, doctor's, or other health care provider's office, provide its certification number, name, and professional qualifications.
(1) If requested
by the physician, doctor, or other health care provider, the URA must present
written documentation that it is acting as an agent of the payor for the
relevant enrollee.
(2) Medical
records and enrollee specific information must be maintained by the URA in a
secure area with access limited to essential personnel only.
(3) A URA must retain information generated
and obtained by a URA in the course of utilization review for at least four
years.
(4) A URA's charges for
providing a copy of recorded personal information to individuals may not exceed
10 cents per page and may not include any costs that are otherwise recouped as
part of the charge for utilization review.
(b) Written procedures on confidentiality.
(1) The URA must specify in writing the
procedures that the URA will implement pertaining to confidentiality of
information received from the enrollee; the individual acting on behalf of the
enrollee; and the physician, doctor, or other health care provider and the
information exchanged between the URA and third parties for conducting
utilization review. These procedures must specify that:
(A) specific information received from the
enrollee; the individual acting on behalf of the enrollee; and the physician,
doctor, or other health care provider and the information exchanged between the
URA and third parties for conducting reviews will be considered confidential,
be used by the review agent solely for utilization review, and be shared by the
URA with only those third parties who have authority to receive the
information, for example, the claim administrator; and
(B) the URA has procedures in place to
address confidentiality and that the URA agrees to abide by any federal and
state laws governing confidentiality.
(2) Summary data which does not provide
sufficient information to allow identification of individual enrollees,
physicians, doctors, or other health care providers is not considered
confidential.
Disclaimer: These regulations may not be the most recent version. Texas may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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