(a) A utilization review agent shall allow any party whose appeal of an adverse determination is denied by the agent to seek review of that determination by an independent review organization assigned to the appeal in accordance with Chapter 4202.
(b) The utilization review agent shall comply with the independent review organization’s determination regarding the medical necessity or appropriateness of health care items and services for an enrollee.

Terms Used In Texas Insurance Code 4201.401

  • 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.

(c) The utilization review agent shall comply with the independent review organization’s determination regarding the experimental or investigational nature of health care items and services for an enrollee.

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