| (2) all work hardening or work conditioning services;
(3) physical and occupational therapy services as referenced
in subsection (p)(5) of this section;
(4) investigational or experimental services or use
of devices;
(5) chronic pain management/interdisciplinary pain
rehabilitation; and
(6) required treatment plans.
(r) The requestor and insurance carrier may voluntarily
discuss health care that does not require preauthorization or concurrent
utilization review under subsections (p) and (q) of this section respectively.
(1) Denial of a request for voluntary certification
is not subject to dispute resolution for prospective review of medical
necessity.
(2) The insurance carrier may certify health care requested.
The carrier and requestor shall document the agreement. Health care
provided as a result of the agreement is not subject to retrospective
utilization review of medical necessity.
(3) If there is no agreement between the insurance
carrier and requestor, health care provided is subject to retrospective
utilization review of medical necessity.
(s) An increase or decrease in review and preauthorization
controls may be applied to individual doctors or individual workers'
compensation claims by the division in accordance with Labor Code §408.0231(b)(4)
and other sections of this title.
(t) The insurance carrier shall maintain accurate records
to reflect information regarding requests for preauthorization, or
concurrent utilization review approval or adverse determination decisions,
and appeals, including requests for reconsideration and requests for
medical dispute resolution, if any. The insurance carrier shall also
maintain accurate records to reflect information regarding requests
for voluntary certification approval/denial decisions. Upon request
of the division, the insurance carrier shall submit such information
in the form and manner prescribed by the division.
(u) For the purposes of this section, all utilization
review must be performed by an insurance carrier that is registered
with, or a utilization review agent that is certified by, the Texas
Department of Insurance to perform utilization review in accordance
with Insurance Code Chapter 4201 and Chapter 19 of this title (relating
to Licensing and Regulation of Insurance Professionals).
(1) All utilization review agents or registered insurance
carriers who perform utilization review under this section must comply
with Labor Code §504.055 and any other provisions of Chapter
19, Subchapter U of this title (relating to Utilization Reviews for
Health Care Provided under Workers' Compensation Insurance Coverage)
that relate to the expedited provision of medical benefits to first
responders employed by political subdivisions who sustain a serious
bodily injury in the course and scope of employment.
(2) In accordance with Labor Code §501.028(b),
an insurance carrier must accelerate and give priority to a claim
for medical benefits:
(A) by a member of the Texas military forces who,
(i) while on state active duty,
(ii) sustains a serious bodily injury, as defined by
Penal Code §1.07;
(B) including all health care required to cure or relieve
the effects naturally resulting from a compensable injury.
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| Source Note: The provisions of this §134.600 adopted to be effective December 23, 1991, 16 TexReg 7099; amended to be effective April 1, 1997, 22 TexReg 1317; amended to be effective January 1, 2002, 26 TexReg 9874; amended to be effective January 1, 2003, 27 TexReg 12359; amended to be effective March 14, 2004, 29 TexReg 2349; amended to be effective May 2, 2006, 31 TexReg 3566; amended to be effective July 1, 2012, 37 TexReg 2420; amended to be effective March 30, 2014, 39 TexReg 2102; amended to beeffective November 1, 2018, 43 TexReg 7174; amended to be effective December 28, 2023, 48 TexReg 8001 |
