The following words and terms, when used in this chapter, shall
have the following meanings, unless the context clearly indicates
otherwise:
(1) Adverse determination--A determination by a utilization
review agent made on behalf of a payor that the health care services
provided or proposed to be provided to an injured employee are not
medically necessary or appropriate. The term does not include a denial
of health care services due to the failure to request prospective
or concurrent utilization review. An adverse determination does not
include a determination that health care services are experimental
or investigational.
(2) Agent--A person whom a system participant utilizes
or contracts with for the purpose of providing claims service or fulfilling
medical bill processing obligations under Labor Code, Title 5 and
rules. The system participant who utilizes or contracts with the agent
may also be responsible for the administrative violations of that
agent. This definition does not apply to "agent" as used in the term
"pharmacy processing agent."
(3) Bill review--Review of any aspect of a medical
bill, including retrospective review, in accordance with the Labor
Code, the Insurance Code, division or department rules, and the appropriate
fee and treatment guidelines.
(4) Complete medical bill--A medical bill that contains
all required fields as set forth in the billing instructions for the
appropriate form specified in §133.10 of this chapter (relating
to Required Billing Forms/Formats), or as specified for electronic
medical bills in §133.500 of this chapter (relating to Electronic
Formats for Electronic Medical Bill Processing).
(5) Emergency--Either a medical or mental health emergency
as follows:
(A) a medical emergency is the sudden onset of a medical
condition manifested by acute symptoms of sufficient severity, including
severe pain, that the absence of immediate medical attention could
reasonably be expected to result in:
(i) placing the patient's health or bodily functions
in serious jeopardy, or
(ii) serious dysfunction of any body organ or part;
(B) a mental health emergency is a condition that could
reasonably be expected to present danger to the person experiencing
the mental health condition or another person.
(6) Final action on a medical bill--
(A) sending a payment that makes the total reimbursement
for that bill a fair and reasonable reimbursement in accordance with §134.1
of this title (relating to Medical Reimbursement); and/or
(B) denying a charge on the medical bill.
(7) Pharmacy processing agent--A person or entity that
contracts with a pharmacy in accordance with Labor Code §413.0111,
establishing an agent or assignee relationship, to process claims
and act on behalf of the pharmacy under the terms and conditions of
a contract related to services being billed. Such contracts may permit
the agent or assignee to submit billings, request reconsideration,
receive reimbursement, and seek medical dispute resolution for the
pharmacy services billed.
(8) Reasonable opportunity--At least one documented
good faith attempt to contact the provider of record that provides
an opportunity for the provider of record to discuss the services
under review with the utilization review agent during normal business
hours prior to issuing a prospective, concurrent, or retrospective
utilization review adverse determination:
(A) no less than one working day prior to issuing a
prospective utilization review adverse determination;
(B) no less than five working days prior to issuing
a retrospective utilization review adverse determination; or
(C) prior to issuing a concurrent or post-stabilization
review adverse determination.
(9) Retrospective utilization review--A form of utilization
review for health care services that have been provided to an injured
employee. Retrospective utilization review does not include review
of services for which prospective or concurrent utilization reviews
were previously conducted or should have been previously conducted.
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| Source Note: The provisions of this §133.2 adopted to be effective May 2, 2006, 31 TexReg 3544; amended to be effective July 27, 2008, 33 TexReg 5701; amended to be effective July 1, 2012, 37 TexReg 2408; amended to be effective March 30, 2014, 39 TexReg 2095 |
