Texas § IN.4201.304 - TIME FOR NOTICE OF ADVERSE DETERMINATION

§ IN.4201.304. TIME FOR NOTICE OF ADVERSE DETERMINATION

TIME FOR NOTICE OF ADVERSE DETERMINATION. (a) Subject to Subsection (b), a utilization review agent shall provide notice of an adverse determination required by this subchapter as follows: (1) with respect to a patient who is hospitalized at the time of the adverse determination, within one working day by either telephone or electronic transmission to the provider of record, followed by a letter within three working days notifying the patient and the provider of record of the adverse determination; (2) with respect to a patient who is not hospitalized at the time of the adverse determination, within three working days in writing to the provider of record and the patient; or (3) within the time appropriate to the circumstances relating to the delivery of the services to the patient and to the patient's condition, provided that when denying poststabilization care subsequent to emergency treatment as requested by a treating physician or other health care provider, the agent shall provide the notice to the treating physician or other health care provider not later than one hour after the time of the request. (b) A utilization review agent shall provide notice of an adverse determination for a concurrent review of the provision of prescription drugs or intravenous infusions for which the patient is receiving health benefits under the health insurance policy not later than the 30th day before the date on which the provision of prescription drugs or intravenous infusions will be discontinued. 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. 4, eff. September 1, 2015.