Texas Administrative Code
Title 28 - INSURANCE
Part 1 - TEXAS DEPARTMENT OF INSURANCE
Chapter 19 - LICENSING AND REGULATION OF INSURANCE PROFESSIONALS
Subchapter U - UTILIZATION REVIEWS FOR HEALTH CARE PROVIDED UNDER WORKERS' COMPENSATION INSURANCE COVERAGE
Section 19.2002 - Applicability
Universal Citation: 28 TX Admin Code § 19.2002
Current through Reg. 50, No. 13; March 28, 2025
(a) Limitations on applicability. Except as provided in Insurance Code Chapter 4201, this subchapter applies to utilization review performed under workers' compensation insurance coverage. This subchapter does not affect the authority of TDI-DWC to exercise the powers granted to it under Labor Code Title 5 and Insurance Code Chapter 4201. This subchapter applies to utilization review as set forth in Insurance Code Chapters 1305 and 4201 and Labor Code Title 5.
(1) This subchapter does not apply to
utilization review performed under a health benefit plan or a health insurance
policy.
(2) This subchapter does
not apply to a person who provides information to an injured employee or an
injured employee's representative, physician, doctor, or other health care
provider about scope of coverage or benefits provided for under workers'
compensation insurance coverage, and does not determine medical necessity or
appropriateness or the experimental or investigational nature of health care
services.
(b) Applicability of other law.
(1) Health care
providers performing peer reviews regarding the prospective, concurrent, or
retrospective review of the medical necessity or appropriateness of health care
are performing utilization review, must generate a written report, and must
comply with this subchapter, Labor Code Title 5, and rules adopted under the
Texas Workers' Compensation Act including, but not limited to, Chapter 180 of
this title (relating to Monitoring and Enforcement).
(2) Insurance carriers must process medical
bills as required by Labor Code Title 5 and rules adopted under the Texas
Workers' Compensation Act including, but not limited to, Chapter 133,
Subchapter A, of this title (relating to General Rules for Medical Billing and
Processing).
(3) If there is a
conflict between this subchapter and rules adopted by the commissioner of
workers' compensation, the rules adopted by the commissioner of workers'
compensation prevail.
(4) If there
is a conflict between this subchapter and the rules in Chapter 10 of this
title, regarding Workers' Compensation Health Care Networks, the rules in
Chapter 10 of this title prevail.
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