Independent review must be conducted under an independent review
plan that is consistent with standards developed with input from appropriate
health care providers, and reviewed and approved by the IRO's medical
director. The independent review plan must include the following components:
(1) a description of the elements of review that the
IRO provides;
(2) written procedures for:
(A) notification of the IRO's determinations provided
to the patient or a representative of the patient, the patient's provider
of record, and the utilization review agent, under §12.206 of
this chapter;
(B) review, including:
(i) any form used during the review process;
(ii) time frames that must be met during the review;
(C) accessing appropriate specialty review;
(D) contacting and receiving information from health
care providers under §12.205 of this chapter;
(3) required use of written medically acceptable review
criteria that are:
(A) based on medical and scientific evidence and use
evidence-based standards, or if evidence is not available, generally
accepted standards of medical practice recognized in the medical community;
(B) established and periodically evaluated and updated
with appropriate involvement from physicians, including practicing
physicians, and other health care providers;
(C) objective, clinically valid, compatible with established
principles of health care, and flexible enough to allow for deviations
from the norms when justified on a case-by-case basis;
(D) developed based on consideration of the treatment
guidelines, treatment protocols, and the pharmacy closed formulary
as provided in orders issued or rules adopted by TDI-DWC, including
Chapter 134 and Chapter 137 of this title for health care provided
under Labor Code Title 5;
(E) used only as a tool in the review process; and
(F) available for review, inspection, and copying as
necessary by the commissioner or the commissioner's designated representative
so the commissioner can carry out the commissioner's lawful duties
under the Insurance Code;
(4) independent review determinations that:
(A) use review procedures that are established and
periodically evaluated and updated with appropriate involvement from
physicians, including practicing physicians, and other health care
providers;
(B) are made with medically accepted review criteria,
taking into account the special circumstances of each case that may
require a deviation from the norm; and
(C) are made by physicians, dentists, or other health
care providers, as appropriate.
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| Source Note: The provisions of this §12.201 adopted to be effective November 26, 1997, 22 TexReg 11363; amended to be effective December 26, 2010, 35 TexReg 11281; amended to be effective July 7, 2015, 40 TexReg 2538 |
