| (a) Applicability. This rule is to be applied as follows. (1) This rule applies to the independent review of prospective or retrospective medical necessity disputes (a review of health care requiring preauthorization or concurrent review, or retrospective review of health care provided) for which the dispute resolution request was filed on or after January 1, 2003. Dispute resolution requests filed prior to January 1, 2003 shall be resolved in accordance with the rules in effect at the time the request was filed. When applicable, retrospective medical necessity disputes shall be governed by the provisions of §133.309 of this title (relating to Alternate Medical Necessity Dispute Resolution by Case Review Doctor), effective for dispute resolution requests filed on or after October 1, 2004. All independent review organizations (IROs) performing reviews of health care under the Texas Workers' Compensation Act (the Act), regardless of where the independent review activities are based, shall comply with this rule. (2) The review of medical necessity by an IRO will be determined in the following priority: (A) prospective medical necessity disputes; (B) employee reimbursement disputes; and (C) retrospective medical necessity disputes. (b) TDI Rules. Each IRO performing independent review of health care provided in the workers' compensation system shall be certified by TDI pursuant to Art. 21.58C, of the Texas Administrative Code, and must comply with TDI rules regarding General Provisions and Certification of IROs, Title 28, Part 1, Chapter 12, Subchapters A and B. In addition, TDI rules in Title 28, Part 1, Chapter 12, Subchapters C through F apply to workers' compensation cases except as modified or noted below: (1) Where the word "patient" is used in those TDI rules, it shall mean the injured employee. (2) Where any of the terms "health insurance carrier," "health maintenance organization," or "managed care entity" is used in those TDI rules, it shall mean the carrier or its agent. (3) The Texas Labor Code and commission rules govern the independent review process and related substantive areas, including: requests, filing, notification, time deadlines, parties, billing, payment, appeal from an adverse IRO decision, and other matters addressed in this rule. (4) A provider who has been removed from the commission Approved Doctor List is not eligible to direct or conduct independent reviews of workers' compensation cases. (5) The provisions regarding a "life-threatening condition" are not applicable because in the workers' compensation system, emergency health care does not require prospective approval. (6) In addition to confidentiality requirements in those TDI rules, an IRO shall preserve the confidentiality of claim file information that is confidential pursuant to the Texas Labor Code. (7) Conflicts of interest will not be screened by TDI; the commission shall screen for conflicts of interest to the extent reasonably possible. (Notification of each IRO decision must include a certification by the IRO that the reviewing provider has certified that no known conflicts of interest exist between that provider and any of the treating providers or any of the providers who reviewed the case for determination prior to referral to the IRO.) (8) The commission will monitor the activity, quality and outcomes of IRO decisions. (c) Parties. The following persons are allowed to be requestors and respondents in medical necessity dispute resolution: (1) In a retrospective necessity dispute - the provider who was denied payment for health care rendered, the employee denied reimbursement for health care for which the employee paid, and the carrier. (2) In a prospective preauthorization dispute - persons or entities as established in §134.600 of this title (relating to Procedure for Requesting Pre-Authorization of Specific Treatments and Services). (3) In a prospective concurrent review dispute - the provider and the carrier. (d) Requests. A request for independent review of a medical necessity dispute shall be timely filed by the requestor with the division. (e) Timeliness. A person or entity who fails to timely file a request waives the right to independent review or medical dispute resolution. The commission shall deem a request to be filed on the date the division receives the request, and timeliness shall be determined as follows: (1) A request for retrospective necessity dispute resolution of a medical bill pursuant to §133.304, of this title (relating to Medical Payments and Denials), shall be considered timely if it is filed with the division no later than one (1) year after the date(s) of service in the dispute. (2) A request for prospective necessity dispute resolution shall be considered timely if it is filed with the division no later than the 45th day after the date the carrier denied approval of the party's request for reconsideration of denial of health care that requires preauthorization or concurrent review pursuant to the provisions of §134.600. (f) Request (General). A request for independent review must be filed in the form, format, and manner prescribed by the commission. The requestor shall file two copies of the request with the division by any mail service or personal delivery, the division will forward one copy of the request to the insurance carrier via its Austin representative, the representative shall sign for the request. Each copy of the request shall be legible, shall include only a single copy of each document, and shall include: (1) A designation that the request is for review by Independent Review Organization; (2) Written notices of adverse determinations (both initial and reconsideration) of prospective or retrospective necessity disputes, if in the possession of the requestor; (3) Documentation of the request for and response to reconsideration, or, if the respondent failed to respond to a request for reconsideration, convincing evidence of carrier receipt of that request; (4) For medical necessity disputes: (A) for retrospective necessity disputes, a table of disputed health care denied for lack of medical necessity, which includes complete details of the dispute issues in accordance with §133.304; or (B) for prospective necessity disputes, a detailed description of the health care requiring preauthorization and/or concurrent review and approval in accordance with §134.600; (5) A list of any and all providers that have examined or provided health care to the employee during the course of the workers' compensation claim; (6) list of all providers that participated in the review or determination by the carrier, if known by the requestor; and (7) if the carrier has raised a dispute pertaining to liability for the claim, compensability, or extent of injury, in accordance with §124.2 of this title (relating to Carrier Reporting and Notification Requirements), the request for an IRO will be held in abeyance until those disputes have been resolved by a final decision of the commission. (g) Carrier Notification to the Commission. The carrier shall complete the remaining sections of the request form and shall provide any missing information required on the form, which shall include: (1) The respondent information; (2) A list of any additional providers that have examined, provided, or rendered health care to the employee at any time during the course of the worker's compensation claim; (3) Notices of adverse determinations of prospective or retrospective medical necessity, not provided by the requestor; and (4) A list of all providers that participated in the review or determination by the carrier, if known by the requestor. (h) Response. The carrier shall file the response to the request with the division and the requestor by facsimile or other electronic means within seven (7) calendar days of receipt of the request for review by the IRO for prospective preauthorization disputes and 14 calendar days for retrospective medical necessity disputes. (i) Dismissal. A dismissal does not constitute a decision. The commission may dismiss a request for medical necessity dispute resolution if: (1) The requestor informs the commission, or the commission otherwise determines, that the dispute no longer exists; (2) The individual or entity requesting medical necessity dispute resolution is not a proper party to the dispute per subsection (c) of this section; (3) The commission determines that the medical bills in the dispute have not been properly submitted to the carrier for reconsideration pursuant to §133.304; (4) The fee disputes for the date(s) of health care in dispute have been previously adjudicated by the commission; (5) The request for dispute resolution is untimely; Cont'd... |
