| (a) If a URA must reimburse health care providers for
providing medical information under Insurance Code §4201.207,
reimbursement is limited to the reasonable costs for providing medical
records relevant to the utilization review that were requested by
the URA in writing. A health care provider's charge for providing
medical information to a URA must comply with §134.120 of this
title (relating to Reimbursement for Medical Documentation) and may
not include any costs that are recouped as a part of the charge for
health care. Nothing in this subsection removes the health care provider's
requirement to provide information to substantiate the medical necessity
of health care requested under Chapter 134 of this title (relating
to Benefits--Guidelines for Medical Services, Charges, and Payments)
or to submit required documentation when submitting a medical bill
under Chapter 133 of this title (relating to General Medical Provisions).
(b) When conducting utilization review, a URA must
request all relevant and updated information and medical records to
complete the review.
(1) This information may include identifying information
about the injured employee; the claim; the treating physician, doctor,
or other health care provider; and the facilities rendering care.
It may also include clinical and diagnostic testing information regarding
the diagnoses of the injured employee and the medical history of the
injured employee relevant to the diagnoses and the compensable injury,
the injured employee's prognosis, and the plan of treatment prescribed
by the provider of record, along with the provider of record's justification
for the plan of treatment. The required information should be requested
from the appropriate sources.
(2) A URA must not routinely request copies of all
medical records on injured employees reviewed. During utilization
review, copies of the necessary or pertinent sections of medical records
should only be required when a difficulty develops in determining
whether the health care is medically necessary or appropriate or experimental
or investigational in nature.
(c) The URA must share among its various divisions
all clinical and demographic information on individual injured employees
to avoid duplicate requests for information from injured employees,
physicians, doctors, and other health care providers.
(d) A URA may not require as a condition of approval
of a health care service, or for any other reason, the observation
of a psychotherapy session or 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 injured employee'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 the URA from requiring submission of:
(1) an injured employee's mental health medical record
summary; or
(2) 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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