This subchapter does not affect the authority of the Texas Workers' Compensation Commission to exercise the powers granted to that commission under Title 5, Labor Code. This subchapter does not apply to a utilization review agent or other person which conducts only the functions of categories of utilization review listed in paragraphs (1)-(3) of this section:

1. (1) a person who provides information to injured employees, their representatives and/or health care providers about scope of coverage or benefits provided for under workers' compensation insurance coverage and who does not determine whether particular health care provided or to be provided to an injured employee is medically reasonable and necessary;
2. (2) a doctor, as defined in §19.2003 of this title (relating to Definitions), or any other individual licensed to provide health care, performing utilization review who is an employee of, or a contractor to, a certified utilization review agent;

3. (3) a utilization review agency which conducts only the categories of utilization review listed in subparagraphs (A)-(D) of this paragraph:

   1. (A) reviews performed pursuant to any contract with the federal government for utilization review of patients eligible for services under Title XVIII or XIX of the Social Security Act (42 United States Code §§1395 et seq. or §§1396 et seq.);
   2. (B) reviews performed for the Texas Medicaid Program, except reviews performed by a health maintenance organization that contracts with the Health and Human Services Commission or an agency operating part of the state Medicaid managed care program to provide health care services to recipients of medical assistance under Chapter 32, Human Resources Code, the Chronically Ill and Disabled Children's Services Program created pursuant to Chapter 35, Health and Safety Code, any program administered under Title 2, the Human Resources Code, any program of the Texas Department of Mental Health and Mental Retardation, or any program of the Texas Department of Criminal Justice;
   3. (C) reviews of health care services provided under a policy or contract of automobile insurance promulgated by the department under the Insurance Code, Subchapter A, Chapter 5 or issued pursuant to the Insurance Code Article 1.14; or
   4. (D) reviews that apply to the terms and benefits of the employee welfare benefit plans as defined in Section 3(1) of the Employee Retirement Income Security Act of 1974 (29 U.S.C. Section 1002(1)).

Source Note:The provisions of this §19.2002 adopted to be effective September 20, 1998, 23 TexReg 9560.