(a) Qualification requirements. Physicians, doctors,
and other health care providers employed by or under contract with
a URA to perform utilization review must be appropriately trained,
qualified, and currently licensed. Personnel conducting utilization
review must hold an unrestricted license or an administrative license
in Texas or be otherwise authorized to provide health care services
in Texas. Physicians and doctors conducting utilization review must
hold a professional certification in a health care specialty appropriate
to the type of health care the injured employee is receiving as required
by Labor Code §§408.0043, 408.0044, and 408.0045. Physicians,
doctors, and other health care providers conducting utilization review
must have the appropriate credentials as required by Chapter 180 of
this title (relating to Monitoring and Enforcement).
(1) This subchapter does not supersede requirements
in the Medical Practice Act, Texas Medical Board rules, Texas Occupations
Code Chapter 201 (relating to Chiropractors), or Texas Board of Chiropractic
Examiners rules. Individuals licensed by the Texas Medical Board are
subject to 22 TAC Chapter 190, regarding disciplinary guidelines.
(2) Personnel who perform clerical or administrative
tasks are not required to have the qualifications prescribed by this
subsection.
(b) Disqualifying associations. For purposes of this
subsection, being employed by or under contract with the same URA
as the physician, doctor, or other health care provider who issued
the initial adverse determination does not in itself constitute a
disqualifying association. A physician, doctor, or other health care
provider who conducts utilization review must not have any disqualifying
associations with the:
(1) injured employee or health care provider who is
requesting utilization review or an appeal; or
(2) physician, doctor, or other health care provider
who issued the initial adverse determination.
(c) Information a URA must send to TDI. A URA must
send to TDI the name, type, Texas license number, and qualifications
of the personnel either employed or under contract to perform utilization
review with an original or renewal application.
(d) Written procedures and maintenance of records.
A URA must develop and implement written procedures, and maintain
documentation, to demonstrate that all physicians, doctors, and other
health care providers used by the URA are licensed, qualified, and
appropriately trained or experienced.
(e) Physician direction requirement. Utilization review
conducted by a URA must be under the direction of a physician currently
licensed without restriction to practice medicine in Texas. The physician
must be employed by or under contract with the URA.
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