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TITLE 28 | INSURANCE |
PART 1 | TEXAS DEPARTMENT OF INSURANCE |
CHAPTER 19 | LICENSING AND REGULATION OF INSURANCE PROFESSIONALS |
SUBCHAPTER U | UTILIZATION REVIEWS FOR HEALTH CARE PROVIDED UNDER WORKERS' COMPENSATION INSURANCE COVERAGE |
RULE §19.2010 | Requirements Prior to Issuing Adverse Determination |
In any instance in which a URA is questioning the medical necessity or appropriateness of the health care services prior to issuance of an adverse determination, the URA must afford the provider of record a reasonable opportunity to discuss the plan of treatment for the injured employee with a physician, dentist, or chiropractor. If the health care services in question are dental services, then a dentist may conduct the discussion if the services in question are within the scope of the dentist's license to practice dentistry. If the health care services in question are chiropractic services, then a chiropractor may conduct the discussion if the services in question are within the scope of the chiropractor's license to practice chiropractic. The discussion must include, at a minimum, the clinical basis for the URA's decision and a description of documentation or evidence, if any, that can be submitted by the provider of record that, on appeal, might lead to a different utilization review decision. |
Source Note: The provisions of this §19.2010 adopted to be effective February 20, 2013, 38 TexReg 892 |