In any instance in which a URA is questioning the medical necessity
or appropriateness of the health care services prior to issuance of
an adverse determination, the URA must afford the provider of record
a reasonable opportunity to discuss the plan of treatment for the
injured employee with a physician, dentist, or chiropractor. If the
health care services in question are dental services, then a dentist
may conduct the discussion if the services in question are within
the scope of the dentist's license to practice dentistry. If the health
care services in question are chiropractic services, then a chiropractor
may conduct the discussion if the services in question are within
the scope of the chiropractor's license to practice chiropractic.
The discussion must include, at a minimum, the clinical basis for
the 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 URA must provide the URA's telephone number
so the provider of record may contact the URA to discuss the pending
adverse determination.
(2) The URA must maintain, and submit to TDI or TDI-DWC
on request, documentation that details the discussion opportunity
provided to the provider of record, including the date and time the
URA offered the opportunity to discuss the adverse determination,
the date and time that the discussion, if any, took place, and the
discussion outcome.
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