(a) Life-threatening conditions.
(1) Notification for life-threatening conditions. For
life-threatening conditions, notification of an adverse determination
by a URA must comply with:
(A) Section 134.600 of this title (relating to Preauthorization,
Concurrent Review, and Voluntary Certification of Health Care) for
workers' compensation non-network coverage;
(B) Insurance Code §1305.353 and §10.102
of this title (relating to Notice of Certain Utilization Review Determinations;
Preauthorization and Retrospective Review Requirements) for workers'
compensation network coverage; and
(C) Section 19.2009(a)(2) of this title (relating to
Notice of Determinations Made in Utilization Review), including notice
of the independent review process and the procedure for obtaining
a copy of the request for a review by an IRO form. The notice must
describe how to obtain independent review of the adverse determination
and how TDI assigns a request for independent review to an IRO.
(2) Existence of life-threatening condition. An injured
employee, the injured employee's representative, or the injured employee's
provider of record must determine the existence of a life-threatening
condition on the basis that a prudent layperson possessing an average
knowledge of medicine and health would believe that the injured employee's
disease or condition is a life-threatening condition.
(3) Appeal of adverse determination involving life-threatening
condition. Any party who receives an adverse determination involving
a life-threatening condition or whose appeal of an adverse determination
involving a life-threatening condition is denied by the URA may seek
review of the adverse determination by an IRO assigned under Insurance
Code Chapter 4202 and Chapter 12 of this title (relating to Independent
Review Organizations).
(b) Independent review involving life-threatening and
non life-threatening conditions. A URA, or insurance carrier that
made the adverse determination, must notify TDI within one working
day from the date a request for an independent review is received.
The URA, or insurance carrier that made the adverse determination,
must submit the completed request for a review by an IRO form to TDI
through TDI's Internet website.
(1) Assignment of IRO. Within one working day of receipt
of a complete request for independent review, TDI will randomly assign
an IRO to conduct the independent review and notify the URA, the payor,
the IRO, the injured employee or the injured employee's representative,
injured employee's provider of record and any other providers listed
by the URA as having records relevant to the review of the assignment.
(2) Workers' compensation non-network coverage. Additional
requirements for independent review of an adverse determination for
a workers' compensation non-network coverage review are governed by
the Texas Workers' Compensation Act and TDI-DWC rules, including but
not limited to Chapter 133, Subchapter D, of this title (relating
to Dispute of Medical Bills).
(3) Workers' compensation network coverage. Additional
requirements for independent review of an adverse determination for
a workers' compensation network coverage review are governed by Insurance
Code Chapter 1305, TDI rules, and TDI-DWC rules, including but not
limited to Chapter 10, Subchapter F, of this title (relating to Utilization
Review and Retrospective Review) and Chapter 133, Subchapter D, of
this title.
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