| (a) A health care provider may designate one or more
individuals as the initial contact or contacts for IROs seeking routine
information or data. In no event will the designation of an individual
or individuals as the initial contact prevent an IRO or medical director
from also contacting a health care provider or others in his or her
employ where a review might otherwise be unreasonably delayed, or
where the designated individual is unable to provide the necessary
information or data requested by the IRO.
(b) An IRO may not engage in unnecessary or unreasonably
repetitive contacts with the health care provider or patient and must
base the frequency of contacts or reviews on the severity or complexity
of the patient's condition or on necessary treatment and discharge
planning activity.
(c) In addition to pertinent files containing medical
and personal information, the utilization review agent or the health
insurance carrier, health maintenance organization, managed care entity,
or other payor requesting the independent review is responsible for
timely delivering to and ensuring receipt by the IRO of any written
narrative supplied by the patient in compliance with Insurance Code
Chapter 4201 and Chapters 19 and 133 of this title. However, in instances
of a life-threatening condition, the IRO must contact the patient
or patient's representative, and provider directly.
(d) An IRO must notify the department if, within three
working days of receipt of the independent review assignment, the
IRO has not received the pertinent files containing medical and personal
information from the requesting utilization review agent or the health
insurance carrier, health maintenance organization, managed care entity,
or other payor.
(e) An IRO must reimburse health care providers for
the reasonable costs of providing medical information in writing,
including copying and transmitting any patient records or other documents
requested by the IRO. A health care provider's charge for providing
medical information to an IRO must not exceed the cost of copying
set by TDI-DWC rules at §134.120 of this title for records, and
may not include any costs that are otherwise recouped as a part of
the charge for health care. The utilization review agent, health insurance
carrier, health maintenance organization, managed care entity, or
other payor requesting the review must pay these unreimbursed costs
to the health care provider.
(f) Nothing in this section prohibits a patient, the
patient's representative, or a provider of record from submitting
pertinent records to an IRO conducting independent review.
(g) When conducting independent review, the IRO must
request and maintain any information necessary to review the adverse
determination not already provided by the utilization review agent,
health insurance carrier, health maintenance organization, managed
care entity, or other payor. This information may include identifying
information about the patient, the benefit plan, the treating health
care provider, or facilities rendering care. It may also include clinical
information regarding the diagnoses of the patient and the medical
history of the patient relevant to the diagnoses, the patient's prognosis,
or the treatment plan prescribed by the treating health care provider
along with the provider's justification for the treatment plan.
(h) The IRO is required to share all clinical and demographic
information on individual patients among its various divisions to
avoid duplication of requests for information from patients or providers.
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| Source Note: The provisions of this §12.205 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 |
