Texas § IN.4201.357 - EXPEDITED APPEAL FOR DENIAL OF EMERGENCY CARE, CONTINUED HOSPITALIZATION, PRESCRI

§ IN.4201.357. EXPEDITED APPEAL FOR DENIAL OF EMERGENCY CARE, CONTINUED HOSPITALIZATION, PRESCRI

EXPEDITED APPEAL FOR DENIAL OF EMERGENCY CARE, CONTINUED HOSPITALIZATION, PRESCRIPTION DRUGS OR INTRAVENOUS INFUSIONS. (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. 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.