| (a) An IRO must notify the patient or patient's representative,
the patient's provider of record, the utilization review agent, the
payor, and the department of a determination made in an independent
review.
(b) For a situation other than a situation described
in subsection (c) of this section, the notification required by this
section must be mailed or otherwise transmitted no later than the
earlier of:
(1) The 15th day after the date the IRO receives the
information necessary to make a determination; or
(2) the 20th day after the date the IRO receives the
request for the independent review.
(c) In the case of a life-threatening condition, the
provision of prescription drugs or intravenous infusions for which
the patient is receiving benefits under a health insurance policy,
or a review of a step therapy protocol exception request under Insurance
Code §1369.0546, the notification must be by telephone, and followed
by facsimile, email, or other method of transmission no later than
the earlier of:
(1) the third day after the date the IRO receives the
information necessary to make a determination; or with respect to:
(2) a review of a health care service provided to a
person eligible for workers' compensation medical benefits, the eighth
day after the date the IRO receives the request that the determination
be made; or
(3) a review of health care service other than a service
described by paragraph (2) of this subsection, the third day after
the date the IRO receives the request that the determination be made.
(d) Notification of determination by the IRO is required
to include at a minimum:
(1) a listing of all recipients of the notification
of determination as described in subsection (a) of this section, identifying
for each:
(A) the name; and
(B) as applicable to the manner of transmission used
to issue the notification of determination to the recipient:
(i) mailing address;
(ii) facsimile number; or
(iii) email address;
(2) the date of the original notice of the decision,
and if amended for any reason, the date of the amended notification
of decision;
(3) the independent review case number assigned by
the department;
(4) the name of the patient;
(5) a statement about whether the type of coverage
is health insurance, workers' compensation, or workers' compensation
health care network;
(6) a statement about whether the context of the review
is preauthorization, concurrent utilization review, or retrospective
utilization review of health care services;
(7) the name and certificate of registration number
of the IRO;
(8) a description of the services in dispute;
(9) a complete list of the information provided to
the IRO for review, including dates of service and document dates,
where applicable;
(10) a description of the qualifications of the reviewing
physician or provider;
(11) a statement that the review was performed without
bias for or against any party to the dispute and that the reviewing
physician or provider has certified that no known conflicts of interest
exist between the reviewer and:
(A) the patient;
(B) the patient's employer, if applicable;
(C) the insurer;
(D) the utilization review agent;
(E) any of the treating physicians or providers; or
(F) any of the physicians or providers who reviewed
the case for determination before its referral to the IRO, and that
the review was performed without bias for or against any party to
the dispute;
(12) a statement that the independent review was performed
by a health care provider licensed to practice in Texas, if required
by applicable law and of the appropriate professional specialty;
(13) a statement that there is no known conflict of
interest between the reviewer, the IRO, and any officer or employee
of the IRO with:
(A) the patient;
(B) the provider requesting independent review;
(C) the provider of record;
(D) the utilization review agent;
(E) the payor; and
(F) the certified workers' compensation health care
network, if applicable;
(14) a summary of the patient's clinical history;
(15) the review outcome, clearly stating whether medical
necessity or appropriateness exists for each of the health care services
in dispute and whether the health care services in dispute are experimental
or investigational, as applicable;
(16) a determination of the prevailing party, if applicable;
(17) the analysis and explanation of the decision,
including the clinical bases, findings, and conclusions used to support
the decision;
(18) a description and the source of the review criteria
used to make the determination;
(19) a certification by the IRO of the date the decision
was sent to all recipients of the notification of determination as
required in subsection (a) of this section by U.S. Postal Service
or otherwise transmitted in the manner indicated on the form;
(20) for independent reviews of health care services
provided under Labor Code Title 5 or Insurance Code Chapter 1305,
any information required by §133.308 of this title; and
(21) notice of applicable appeal rights under Insurance
Code Chapter 1305 and Labor Code Title 5, and instructions concerning
requesting such appeal.
(e) Example templates for the notification of determination
regarding health and workers' compensation cases are on the department's
website at tdi.texas.gov/forms.
|
| Source Note: The provisions of this §12.206 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; amended to be effective July 28, 2019, 44 TexReg 3906 |
