| (a) Requirements for independent review of an adverse
determination are governed by Insurance Code Chapter 1305, concerning
Workers' Compensation Health Care Networks, and department and Division
of Workers' Compensation rules, including Chapter 10, Subchapter F,
of this title (relating to Utilization Review), Chapter 12 of this
title (relating to Independent Review Organizations), Chapter 19 of
this title (relating to Licensing and Regulation of Insurance Professionals),
and §133.308 of this title (relating to MDR of Medical Necessity
Disputes).
(b) The person who performs utilization review; denies
a referral request because the referral is not medically necessary;
or denies a request for deviation from treatment guidelines, individual
treatment protocols, or screening criteria must:
(1) permit the employee, person acting on behalf of
the employee, or the employee's requesting provider to seek review
of the referral denial or reconsideration denial within the period
prescribed by subsection (c) of this section by an independent review
organization assigned in accordance with Insurance Code Chapter 4202,
concerning Independent Review Organizations, and department and Division
of Workers' Compensation rules; and
(2) provide to the appropriate independent review organization
the information and documents listed in §133.308(k) of this title
(relating to MDR of Medical Necessity Disputes) and the response letter
described by Insurance Code §1305.354(a)(4), concerning Reconsideration
of Adverse Determination, not later than the third business day after
the date the person receives notification of the assignment of the
request to an independent review organization.
(c) A requestor must timely file a request for independent
review under subsection (b) of this section as follows:
(1) for a request regarding preauthorization or concurrent
review, not later than the 45th day after the date of denial of a
reconsideration; or
(2) for a request regarding retrospective medical necessity
review, not later than the 45th day after the denial of reconsideration.
(d) The insurance carrier must pay for the independent
review provided under this subchapter.
(e) The department will assign the review request to
an independent review organization.
(f) A decision of an independent review organization
related to a request for preauthorization or concurrent review is
binding during any review under this section. The carrier is liable
for health care during the pendency of any appeal, and the carrier
and network must comply with the decision.
(g) A party to a medical dispute that remains unresolved
after a review under this section is entitled to a contested case
hearing. A hearing under this section will be conducted by the Division
of Workers' Compensation in the same manner as a hearing conducted
under Labor Code §413.0311, concerning Review of Medical Necessity
Disputes; Contested Case Hearing, and Division of Workers' Compensation
rules.
(h) The department and the Division of Workers' Compensation
are not considered to be parties to the medical dispute.
(i) If review is not sought under subsection (g) of
this section, the carrier and network must comply with the independent
review organization's decision.
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