Texas Insurance Code 4201.303 – Adverse Determination: Contents of Notice
(a) Notice of an adverse determination must include:
(1) the principal reasons for the adverse determination;
(2) the clinical basis for the adverse determination;
(3) a description of or the source of the screening criteria used as guidelines in making the adverse determination; and
(4) a description of the procedure for the complaint and appeal process, including notice to the enrollee of the enrollee’s right to appeal an adverse determination to an independent review organization and of the procedures to obtain that review.
(b) For an enrollee who has a life-threatening condition, the notice required by Subsection (a)(4) must include a description of the enrollee’s right to an immediate review by an independent review organization and of the procedures to obtain that review.
Terms Used In Texas Insurance Code 4201.303
- Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
- Complaint: A written statement by the plaintiff stating the wrongs allegedly committed by the defendant.
(c) For an enrollee who is denied the provision of prescription drugs or intravenous infusions for which the patient is receiving benefits under the health insurance policy, the notice required by Subsection (a)(4) must include a description of the enrollee’s right to an immediate review by an independent review organization and of the procedures to obtain that review.