(a) Notice requirements. A URA must send written notification
to the enrollee or an individual acting on behalf of the enrollee
and the enrollee's provider of record, including the health care provider
who rendered the service, of a determination made in a utilization
review.
(b) Required notice elements. In all instances of a
prospective, concurrent, or retrospective utilization review adverse
determination, written notification of the adverse determination by
the URA must include:
(1) the principal reasons for the adverse determination;
(2) the clinical basis for the adverse determination;
(3) a description or the source of the screening criteria
that were utilized as guidelines in making the determination;
(4) the professional specialty of the physician, doctor,
or other health care provider that made the adverse determination;
(5) a description of the procedure for the URA's complaint
system as required by §19.1705 of this title (relating to General
Standards of Utilization Review);
(6) a description of the URA's appeal process, as required
by §19.1711 of this title (relating to Written Procedures for
Appeal of Adverse Determination);
(7) a copy of the request for a review by an IRO form,
available at www.tdi.texas.gov/forms;
(8) notice of the independent review process with instructions
that:
(A) request for a review by an IRO form must be completed
by the enrollee, an individual acting on behalf of the enrollee, or
the enrollee's provider of record and be returned to the insurance
carrier or URA that made the adverse determination to begin the independent
review process; and
(B) the release of medical information to the IRO,
which is included as part of the independent review request for a
review by an IRO form, must be signed by the enrollee or the enrollee's
legal guardian; and
(9) a description of the enrollee's right to an immediate
review by an IRO and of the procedures to obtain that review for an
enrollee who has a life-threatening condition.
(c) Determination concerning an acquired brain injury.
In addition to the notification required by this section, a URA must
comply with this subsection in regard to a determination concerning
an acquired brain injury as defined by §21.3102 of this title
(relating to Definitions). Not later than three business days after
the date an individual requests utilization review or requests an
extension of coverage based on medical necessity or appropriateness,
a URA must provide notification of the determination through a direct
telephone contact to the individual making the request. This subsection
does not apply to a determination made for coverage under a small
employer health benefit plan.
(d) Prospective and concurrent review.
(1) Favorable determinations. The written notification
of a favorable determination made in utilization review must be mailed
or electronically transmitted as required by Insurance Code §4201.302.
(2) Preauthorization numbers. A URA must ensure that
preauthorization numbers assigned by the URA comply with the data
and format requirements contained in the standards adopted by the
U.S. Department of Health and Human Services in 45 C.F.R. §162.1102,
(relating to Standards for Health Care Claims or Equivalent Encounter
Information Transaction), based on the type of service in the preauthorization
request.
(3) Required timeframes. Except as otherwise provided
by the Insurance Code, the timeframes for notification of the adverse
determination begin from the date of the request and must comply with
Insurance Code §4201.304. A URA must provide the notice to the
provider of record or other health care provider not later than one
hour after the time of the request when denying post-stabilization
care subsequent to emergency treatment as requested by a provider
of record or other health care provider. The URA must send written
notification within three working days of the telephone or electronic
transmission.
(e) Retrospective review.
(1) The URA must develop and implement written procedures
for providing the notice of adverse determination for retrospective
utilization review, including the timeframes for the notice of adverse
determination, that comply with Insurance Code §4201.305 and
this section.
(2) When a retrospective review of the medical necessity
or appropriateness, or the experimental or investigational nature,
of the health care services is made in relation to health coverage,
the URA may not require the submission or review of a mental health
therapist's process or progress notes that relate to the mental health
therapist's treatment of an enrollee's mental or emotional condition
or disorder. This prohibition extends to requiring an oral, electronic,
facsimile, or written submission or rendition of a mental health therapist's
process or progress notes. This prohibition does not preclude requiring
submission of:
(A) an enrollee's mental health medical record summary;
or
(B) medical records or process or progress notes that
relate to treatment of conditions or disorders other than a mental
or emotional condition or disorder.
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