| (a) Applicability. This section applies to the independent review of network and non-network preauthorization, concurrent or retrospective medical necessity disputes for a dispute resolution request filed on or after January 15, 2007. Dispute resolution requests filed prior to January 15, 2007 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 Labor Code §413.031(n) and related rules. All independent review organizations (IROs) performing reviews of health care under the Labor Code and Insurance Code, regardless of where the independent review activities are located, shall comply with this section. The Insurance Code, the Labor Code and related rules govern the independent review process. (b) IRO Certification. Each IRO performing independent review of health care provided in the workers' compensation system shall be certified pursuant to Insurance Code Article 21.58C (Chapter 4202 effective April 1, 2007). (c) Conflicts. Conflicts of interest will be reviewed by the Department consistent with the provisions of the Insurance Code Article 21.58C, §2(f) (§4202.008 effective April 1, 2007), Labor Code §413.032(b), §12.203 of this title (relating to Conflicts of Interest Prohibited), and any other related rules. 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, the employee, any of the treating providers, or any of the providers who reviewed the case for determination prior to referral to the IRO. (d) Monitoring. The Division will monitor IROs under Labor Code §§413.002, 413.0511, and 413.0512. The Division shall report the results of the monitoring of IROs to the Department on at least a quarterly basis. (e) Requestors. The following parties are considered requestors (1) In network disputes: (A) providers, or qualified pharmacy processing agents acting on behalf of a pharmacy, as described in Labor Code §413.0111, for preauthorization, concurrent, and retrospective medical necessity dispute resolution; and (B) employees for preauthorization, concurrent, and retrospective medical necessity dispute resolution. (2) In non-network disputes: (A) providers, or qualified pharmacy processing agents acting on behalf of a pharmacy, as described in Labor Code §413.0111, for preauthorization, concurrent, and retrospective medical necessity dispute resolution; and (B) employees for preauthorization and concurrent medical necessity dispute resolution; and, for retrospective medical necessity dispute resolution when reimbursement was denied for health care paid by the employee. (f) Requests. A request for independent review must be filed in the form and manner prescribed by the Department. The Department's IRO request form may be obtained from: (1) the Department's Internet website at www.tdi.state.tx.us; or (2) the Health and Worker's Compensation Network Certification and Quality Assurance Division, Mail Code 103-6A, Texas Department of Insurance, P.O. Box 149104, Austin, Texas 78714-9104. (g) Timeliness. A requestor shall file a request for independent review with the insurance carrier (carrier) or the carrier's utilization review agent (URA) no later than the 45th calendar day after receipt of the denial of reconsideration. The carrier shall immediately notify the Department upon receipt of the request for an independent review. In a preauthorization or concurrent review dispute request, an employee with a life-threatening condition, as defined in §133.305 of this subchapter (relating to MDR--General), is entitled to an immediate review by an IRO and is not required to comply with the procedures for a reconsideration. (h) Dismissal. The Department may dismiss a request for medical necessity dispute resolution if: (1) the requestor informs the Department, or the Department 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; (3) the Department determines that the dispute involving a non-life-threatening condition has not been submitted to the carrier for reconsideration; (4) the Department has previously resolved the dispute for the date(s) of health care in question; (5) the request for dispute resolution is untimely pursuant to subsection (g) of this section; (6) the request for medical necessity dispute resolution was not submitted in compliance with the provisions of this subchapter; or (7) the Department determines that good cause otherwise exists to dismiss the request. (i) IRO Assignment and Notification. The Department shall review the request for IRO review, assign an IRO, and notify the parties about the IRO assignment consistent with the provisions of Insurance Code Article 21.58C, §2(a)(1)(A) (§4202.002(a)(1) effective April 1, 2007), §1305.355(a), Chapter 12, Subchapter F of this title (related to Random Assignment of Independent Review Organizations), any other related rules, and this subchapter. (j) Carrier Document Submission. The carrier or the carrier's URA shall submit the documentation required in paragraphs (1) - (6) of this subsection to the IRO not later than the third working day after the date the carrier receives the notice of IRO assignment. The documentation shall include: (1) the forms prescribed by the Department for requesting IRO review; (2) all medical records of the employee in the possession of the carrier that are relevant to the review; (3) all documents, guidelines, policies, protocols and criteria used by the carrier in making the decision; (4) all documentation and written information submitted to the carrier in support of the appeal; (5) the written notification of the initial adverse determination and the written adverse determination of the reconsideration; and (6) any other information required by the Department related to a request from a carrier for the assignment of an IRO. (k) Additional Information. The IRO shall request additional necessary information from either party or from other providers whose records are relevant to the review. (1) The party or providers with relevant records shall deliver the requested information to the IRO as directed by the IRO. If the provider requested to submit records is not a party to the dispute, the carrier shall reimburse copy expenses for the requested records pursuant to §134.120 of this title (relating to Reimbursement for Medical Documentation). Parties to the dispute may not be reimbursed for copies of records sent to the IRO. (2) If the required documentation has not been received as requested by the IRO, the IRO shall notify the Department and the Department shall request the necessary documentation. (3) Failure to provide the requested documentation as directed by the IRO or Department may result in enforcement action as authorized by statutes and rules. (l) Designated Doctor Exam. In performing a review of medical necessity, an IRO may request that the Division require an examination by a designated doctor and direct the employee to attend the examination pursuant to Labor Code §413.031(g) and §408.0041. The IRO request to the Division must be made no later than 10 days after the IRO receives notification of assignment of the IRO. The treating doctor and carrier shall forward a copy of all medical records, diagnostic reports, films, and other medical documents to the designated doctor appointed by the Division, to arrive no later than three working days prior to the scheduled examination. Communication with the designated doctor is prohibited regarding issues not related to the medical necessity dispute. The designated doctor shall complete a report and file it with the IRO, on the form and in the manner prescribed by the Division no later than seven working days after completing the examination. The designated doctor report shall address all issues as directed by the Division. (m) Time Frame for IRO Decision. The IRO will render a decision as follows: (1) for life-threatening conditions, no later than eight days after the IRO receipt of the dispute; (2) for preauthorization and concurrent medical necessity disputes, no later than the 20th day after the IRO receipt of the dispute; (3) for retrospective medical necessity disputes, no later than the 30th day after the IRO receipt of the IRO fee; and Cont'd... |
