Utilization Review Licensing in Texas

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Utilization review licenses and certificates are typically issued for organizations conducting either medical or workers’ compensation reviews. This guide contains information about utilization review in Texas. For assistance with licensing, please contact us to learn about our software and managed license services.

Texas Utilization Review Agent Certification

Type of Review:

Medical or Workers' Compensation Utilization Review

Agency:Texas Department of Insurance
Law:

TX Ins Code § 4201.101

Foreign Qualification is Prerequisite:Yes
Notes:

Applicants must choose to apply for certification or registration. Certification is for entities that conduct utilization review for a health benefit plan or health insurance policy; also payors or administrators holding a certificate of authority under TX Ins Code ch. 4201. Registration is for licensed insurance companies or health maintenance organizations that perform utilization review only for their own insureds or enrollees.

Registered Agent (Special Agency) Required?Yes

Initial Registration

Form:

URA Application Form

Agency Fee:

$2,150 for certification. There is no fee for 'registered' applicants.

Notarization Required?:Required
Required Attachments:
  • A summary of the utilization review plan as detailed in the application
  • Categories of personnel as noted in 28 TAC § 19.1706 and 28 TAC § 19.2006
  • Appeal of adverse determination acknowledgement and template letters
  • Telephone access details as noted in 28 TAC § 19.1712 and 28 TAC § 19.2012
  • Written evidence that the applicant is doing business in Texas in accordance with the Texas Business Organizations Code, which may include a letter from the Texas Secretary of State indicating the entity has filed the appropriate paperwork to conduct business in this state
  • A chart showing the internal organizational structure of the applicant’s executives, officers, and directors and the title of the position held by each
  • A letter of good standing from the Texas Comptroller of Public Accounts
  • Completed biographical affidavit and fingerprints for each executive, officer, and director

Registration Renewal

Form:

URA Application Form (Renewal)

Agency Fee:

$545 for certification. There is no fee for 'registered' applicants.

Due:

Biennially by the date of issuance.

Notarization Required?:Required
Required Attachments:
  • Categories of personnel as noted in 28 TAC § 19.1706 and 28 TAC § 19.2006
  • Appeal of adverse determination acknowledgement and template letters

Texas Resources

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Adverse Determination - When a health care plan or utilization review program decides that a medical treatment or service is not necessary.

Concurrent Review - Utilization review that is conducted during a patient’s course of treatment.

External Review - When an independent review organization is consulted to appeal an insurance company’s adverse determination.

Independent Review Organization (IRO) - Unbiased third-parties that conduct utilization review.

Prospective Review - Utilization review that occurs prior to treatment.

Retrospective Review - Utilization review that occurs after treatment and often after payment.

Utilization Review - A system for evaluating the medical necessity, efficiency, and appropriateness of medical services.

Utilization Review Agent (URA) - An entity that conducts utilization review.

Utilization Review Plan - A document of the procedures used during utilization review.

Revised February 18, 2021. Complete data last reviewed January 02, 2018.
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