Texas Insurance Code
§ 843.261 — SPECIAL PROVISIONS FOR APPEALS OF ADVERSE DETERMINATIONS
IN § 843.261Title 6. ORGANIZATION OF INSURERS AND RELATED ENTITIES · Part C. LIFE, HEALTH, AND ACCIDENT INSURERS AND RELATED ENTITIES · Ch. 843. HEALTH MAINTENANCE ORGANIZATIONS · Art. G. DISPUTE RESOLUTION
Statute text
View on source(a)A health maintenance organization shall implement and maintain an internal appeal system that:
(1)provides reasonable procedures for the resolution of an oral or written appeal concerning dissatisfaction or disagreement with an adverse determination; and
(2)includes procedures for notification, review, and appeal of an adverse determination in accordance with Chapter 4201.
(b)An appeal must be initiated by an enrollee, a person acting on behalf of an enrollee, or an enrollee's provider of record.
(c)When an enrollee, a person acting on behalf of an enrollee, or an enrollee's provider of record expresses orally or in writing any dissatisfaction or disagreement with an adverse determination, the health maintenance organization or utilization review agent shall:
(1)consider the expression of dissatisfaction or disagreement as an appeal of the adverse determination; and
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Legislative history
Acts 2007, 80th Leg., R.S., Ch. 730 (H.B. 2636), Sec. 2E.046, eff. April 1, 2009.