SECTION 3.8003. Criteria

In all chemical dependency treatment utilization review decisions respecting coverage providing benefits for necessary care and treatment, each payor and treatment provider shall use the standards and corresponding criteria in this subchapter; on and after June 1, 1992, utilization review decisions shall comply with all applicable requirements of the Insurance Code, Article 21.58A. These decisions include admission to treatment, the appropriate level of chemical dependency treatment, continuing treatment, transferring to different levels of treatment, or discharge from treatment. Each payor and treatment provider shall also use this set of standards and corresponding criteria to guide decisions concerning reasonable periods of treatment at particular levels of treatment in a chemical dependency treatment center, as defined in §3.8001 of this title (relating to Definitions) or in the Insurance Code, Article 3.51-9. These standards and corresponding criteria define the conditions under which benefits shall be provided for the necessary care and treatment of chemical dependency. These standards and corresponding criteria are not intended to, nor are they in any way or manner to be construed to, establish standards of clinical care or appropriate clinical practice. The standards and corresponding criteria set forth in this subchapter include recommended lengths of stay for treatment. These recommended lengths of stay are not intended to, nor are they in any way or manner to be construed to, establish absolute minimum or maximum periods for treatment. Initial and continued eligibility for treatment is to be predicated on the patient meeting the standards and corresponding criteria set forth in this subchapter. Disputes resulting from utilization review decisions respecting necessary care and treatment shall be settled on the basis of the criteria in this subchapter; additionally, on and after June 1, 1992, disputes resulting from utilization review decisions respecting necessary care and treatment shall be settled in accordance with applicable requirements of the Insurance Code, Article 21.58A.

Source Note: The provisions of this §3.8003 adopted to be effective August 28, 1991, 16 TexReg 4403