SECTION 3.9212. Appeal of Non-Medicaid Adverse Determinations

An issuer must perform utilization review in compliance with Insurance Code Chapter 4201 and must maintain procedures for notification, review, and appeal of an adverse determination, as defined by this section. An issuer must implement and maintain an internal appeal system for non-Medicaid adverse determinations that provides reasonable procedures for the resolution of an oral or written appeal initiated by an insured, a person acting on behalf of an insured, or an insured's provider of record concerning dissatisfaction or disagreement with an adverse determination.

Source Note: The provisions of this §3.9212 adopted to be effective September 17, 2003, 28 TexReg 7993; amended to be effective May 11, 2022, 47 TexReg 2758