| (27) Provider of record--The physician, doctor, or
other health care provider that has primary responsibility for the
health care services rendered or requested on behalf of an injured
employee, or a physician, doctor, or other health care provider that
has rendered or has been requested to provide health care services
to an injured employee. This definition includes any health care facility
where health care services are rendered on an inpatient or outpatient
basis.
(28) 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 URA 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.
(29) Registration--The process for an insurance carrier
to register with TDI to perform utilization review solely for injured
employees covered by workers' compensation insurance coverage issued
by the insurance carrier.
(30) Request for a review by an IRO--Form to request
a review by an independent review organization that is completed by
the requesting party and submitted to the URA, or insurance carrier
that made the adverse determination.
(31) 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.
(32) Screening criteria--The written policies, decision
rules, medical protocols, or treatment guidelines used by a URA as
part of the utilization review process.
(33) TDI--The Texas Department of Insurance.
(34) TDI-DWC--The Texas Department of Insurance, Division
of Workers' Compensation.
(35) Texas Workers' Compensation Act--Labor Code Title
5, Subtitle A.
(36) Treating doctor--As defined in Labor Code §401.011.
(37) URA--Utilization review agent.
(38) URA application--Form for application for, renewal
of, and reporting a material change to a certification or registration
as a URA in this state.
(39) Workers' compensation health care network--As
defined in Insurance Code §1305.004.
(40) Workers' compensation health plan--Health care
provided by a political subdivision contracting directly with health
care providers or through a health benefits pool, under Labor Code §504.053(b)(2).
(41) Workers' compensation insurance coverage--As defined
in Labor Code §401.011.
(42) Workers' compensation network coverage--Health
care provided under a workers' compensation health care network.
(43) Workers' compensation non-network coverage--Health
care delivered under Labor Code Title 5, excluding health care provided
under Insurance Code Chapter 1305.
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