| (a) Application. To be certified or registered as a
specialty URA, an applicant must submit to TDI the application, information,
and fee required in §19.1704 of this title (relating to Certification
or Registration of URAs).
(b) Same specialty required. A specialty URA must conduct
utilization review under the direction of a health care provider who
is of the same specialty as the agent and who is licensed or otherwise
authorized to provide the specialty health care service in Texas.
To conduct utilization review, a specialty URA must be of the same
specialty as the health care provider who ordered the service. For
example, when conducting utilization review of prescription drugs
prescribed by a physician with a specialty in neurological surgery,
the specialty URA must be a physician with a specialty in neurological
surgery.
(c) Rule requirements. A specialty URA is subject to
the requirements of this subchapter, except for the following provisions:
(1) Section 19.1705(a) of this title (relating to General
Standards of Utilization Review);
(2) Section 19.1706(a), (c), and (d) of this title
(relating to Requirements and Prohibitions Relating to Personnel);
(3) Section 19.1710 of this title (relating to Requirements
Prior to Issuing Adverse Determination); and
(4) Section 19.1711(a)(4) - (6) of this title (relating
to Written Procedures for Appeal of Adverse Determination).
(d) Utilization review plan. A specialty URA must have
its utilization review plan, including appeal requirements, reviewed
by a health care provider of the appropriate specialty who is licensed
or otherwise authorized to provide the specialty health care service
in Texas, and the plan must be implemented under standards developed
with input from a health care provider of the appropriate specialty
who is licensed or otherwise authorized to provide the specialty health
care service in Texas. The specialty URA must have written procedures
to ensure that these requirements are implemented.
(e) Requirements of employed or contracted physicians,
doctors, other health care providers, and personnel.
(1) Physicians, doctors, other health care providers,
and personnel employed by or under contract with the specialty URA
to perform utilization review must be appropriately trained, qualified,
and currently licensed.
(2) Personnel conducting specialty utilization review
must hold an unrestricted license, an administrative license issued
by a state licensing board, or be otherwise authorized to provide
health care services by a licensing agency in the United States.
(f) Reasonable opportunity for discussion. In any instance
in which a specialty URA questions the medical necessity, the appropriateness,
or the experimental or investigational nature of the health care services,
the health care provider of record must, prior to the issuance of
an adverse determination, be afforded a reasonable opportunity to
discuss the plan of treatment for the patient and the clinical basis
for the decision of the URA with a health care provider of the same
specialty as the URA. The discussion must include, at a minimum, the
clinical basis for the specialty URA's decision and a description
of documentation or evidence, if any, that can be submitted by the
provider of record that, on appeal, might lead to a different utilization
review decision.
(1) The specialty URA's telephone number must be provided
to the provider of record so that the provider of record may contact
the specialty URA to discuss the pending adverse determination. For
a retrospective utilization review, the specialty URA must allow the
provider of record five working days to respond orally or in writing.
(2) The specialty URA must maintain, and submit to
TDI on request, documentation that details the discussion opportunity
provided to the provider of record, including the date and time the
specialty URA offered the opportunity to discuss the adverse determination;
the date and time that the discussion, if any, took place; and the
discussion outcome.
(g) Appeal. The decision in any appeal of an adverse
determination by a specialty URA must be made by a physician or other
health care provider who has not previously reviewed the case and
who is of the same specialty as the specialty URA that made the adverse
determination.
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