Texas Insurance Code 843.261 – Special Provisions for Appeals of Adverse Determinations
Current as of: 2024 | Check for updates
|
Other versions
(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.
Terms Used In Texas Insurance Code 843.261
- 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.
- in writing: includes any representation of words, letters, or figures, whether by writing, printing, or other means. See Texas Government Code 312.011
- Person: includes corporation, organization, government or governmental subdivision or agency, business trust, estate, trust, partnership, association, and any other legal entity. See Texas Government Code 311.005
- Written: includes any representation of words, letters, symbols, or figures. See Texas Government Code 311.005
(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
(2) review and resolve the appeal in accordance with Chapter 4201.
(d) A health maintenance organization may integrate its appeal procedures related to adverse determinations with the complaint and appeal procedures established by the health maintenance organization under § 843.251 and otherwise governed by this subchapter only if the procedures related to adverse determinations comply with this section and Chapter 4201.