| (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 initial dispute resolution request was filed on or
after January 1, 2002. Dispute resolution requests filed prior to January
1, 2002 shall be resolved in accordance with the rules in effect at the time
the request was filed. All independent review organizations (IRO's) 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. An initial request for independent review of
a medical necessity dispute shall be timely filed simultaneously by the requestor,
with the carrier or the respondent and 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 and
the carrier receive the initial 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
carrier and 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 carrier and 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) Initial Request (General). A request for independent review
must be filed in the form, format, and manner prescribed by the commission.
Each 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 (denial codes T, U or V) 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; and
(6) a 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) Filing. The carrier shall file the response to the request
with the division and the requestor by facsimile or other electronic means
within three working days of receipt of the request for review by the IRO.
(i) TWCC Notification of Parties. The commission shall review
the request for IRO review, assign an IRO with which no conflict of interest
exists, and notify the parties and the IRO of the assignment, by regular U.S.
mail service or by transmission of facsimile. The commission will assign disputes
on a rotating basis to the IROs certified by TDI, in accordance with Insurance
Code article 21.58C and TDI rules. The commission may assign disputes in accordance
with the priorities established in this rule and in a manner other than a
rotating basis if necessary because of insufficient IRO capacity.
(j) IRO Notification of Parties. The IRO shall also notify
the parties of the assignment and require that documentation be sent directly
to the assigned IRO and received not later than the seventh day after the
party's receipt of the IRO notice. The documentation shall include:
(1) any medical records of the injured employee relevant to
the review;
(2) any documents used by the utilization review agent or carrier
in making the decision, to be reviewed by the IRO; and
Cont'd... |
