(a) Notice requirements of favorable or adverse determinations.
(1) A URA must send written notification of a determination
made in utilization review to the individuals specified in and within
the timeframes required for utilization review.
(2) For prospective and concurrent review, the timeframes
are specified by:
(A) Section 134.600 of this title (relating to Preauthorization,
Concurrent Review, and Voluntary Certification of Health Care) for
workers' compensation non-network coverage; and
(B) Insurance Code §1305.353, concerning Notice
of Certain Utilization Review Determinations; Preauthorization Requirements;
and §10.102 of this title (relating to Notice of Certain Utilization
Review Determinations; Preauthorization and Retrospective Review Requirements)
for workers' compensation network coverage.
(3) For retrospective review, the timeframes are specified
by:
(A) Sections 133.240 and 133.250 of this title (relating
to Medical Payment and Denials, and Reconsideration for Payment of
Medical Bills, respectively) for workers' compensation non-network
coverage;
(B) Sections 133.240, 133.250, and 10.102 of this title,
for workers' compensation network coverage.
(4) For workers' compensation non-network coverage
and network coverage, a URA must ensure that preauthorization numbers
assigned by the URA comply with the data and format requirements contained
in the standards adopted by the U.S. Department of Health and Human
Services in 45 Code of Federal Regulations §162.1102 (relating
to Standards for Health Care Claims or Equivalent Encounter Information
Transaction) based on the type of service in the preauthorization
request.
(b) Required notice elements. In all instances of a
prospective, concurrent, or retrospective utilization review adverse
determination, written notification of the adverse determination by
the URA must include:
(1) the principal reasons for the adverse determination;
(2) the clinical basis for the adverse determination;
(3) a description of the procedure for filing a complaint
with TDI;
(4) the professional specialty and Texas license number
of the physician, doctor, or other health care provider that made
the adverse determination;
(5) a description of the procedure for the URA's complaint
system as required by §19.2005 of this title (relating to General
Standards of Utilization Review);
(6) a description of the URA's appeal process, as required
by §19.2011 of this title (relating to Written Procedures for
Appeal of Adverse Determination) and a statement that in a circumstance
involving an injured employee's life-threatening condition, the injured
employee is entitled to an immediate review of the adverse determination
by an IRO and is not required to comply with procedures for an internal
review of the adverse determination by the URA for prospective and
concurrent utilization review;
(7) for workers' compensation network coverage, a description
or the source of the screening criteria used in making the determination,
including a description of treatment guidelines used, as applicable;
(8) for workers' compensation non-network coverage,
a description of treatment guidelines used under Chapter 137 of this
title (relating to Disability Management) or Labor Code §504.054(b)
in making a determination; and
(9) notice of the independent review process. The notice
of the independent review process required under this paragraph must
include:
(A) a statement that:
(i) the request for a review by an IRO form must be
completed by the injured employee, the injured employee's representative,
or the injured employee's provider of record and be returned to the
insurance carrier or URA that made the adverse determination to begin
the independent review process;
(ii) a request for independent review of an adverse
determination made under workers' compensation non-network coverage
must be timely filed by the requestor consistent with §133.308
of this title (relating to MDR of Medical Necessity Disputes); and
(iii) a request for independent review of an adverse
determination made under workers' compensation network coverage must
be timely filed by the requestor consistent with §10.104 of this
title (relating to Independent Review of Adverse Determination); and
(B) either of the following:
(i) a copy of the request for a review by an IRO form,
available at www.tdi.texas.gov/forms; or
(ii) notice in at least 12 point font that the injured
employee can obtain a copy of the request for a review by an IRO form
by:
(I) accessing TDI's website at www.tdi.texas.gov/forms;
or
(II) calling {insert URA's telephone number} to request
a copy of the form, at which time the URA will send a copy of the
request for a review by an IRO form to the injured employee.
(c) Peer review reports. The notice of determination
made in utilization review required under this section and the peer
review report required by §180.28 of this title (relating to
Peer Review Requirements, Reporting, and Sanctions) may be combined
into one document if all the requirements of both sections are met.
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