Health Benefit Plan Issuers Contracting with Delegated Entities, Delegated Third Parties, and Utilization Review Agents

(a) Delegations by health benefit plan issuers with nonconditional accreditation. If a health benefit plan issuer with nonconditional accreditation has delegated one or more functions to a delegated entity, delegated third party, or utilization review agent, those delegated functions shall be presumed in compliance with state statutory and regulatory requirements if:

(1) the delegation was in place at the time of the national accreditation organization's review of the health benefit plan issuer; or

(2) the delegated entity, delegated third party, or utilization review agent has received nonconditional accreditation or certification by a national accreditation organization.

(b) Delegations by health benefit plan issuers without nonconditional accreditation. If a health benefit plan issuer without nonconditional accreditation has delegated one or more functions to a delegated entity, delegated third party, or utilization review agent, those delegated functions shall be presumed in compliance with state statutory and regulatory requirements if the delegated entity, delegated third party, or utilization review agent has received nonconditional accreditation or certification by a national accreditation organization that the department recognizes, as set forth in §21.4103 of this subchapter (relating to Presumed Compliance).

Source Note: The provisions of this §21.4104 adopted to be effective May 3, 2007, 32 TexReg 2364.