| (a) Notification for life-threatening conditions. For
life-threatening conditions, notification of adverse determination
by a URA must be provided within the time frames specified in §19.1709(e)(3)
of this title (relating to Notice of Determinations Made in Utilization
Review).
(1) At the time of notification of the adverse determination,
the URA must provide to the enrollee or individual acting on behalf
of the enrollee, and to the enrollee's provider of record, the notice
of the independent review process and a copy of the request for a
review by an IRO form. The notice must describe how to obtain independent
review of the adverse determination.
(2) The enrollee, individual acting on behalf of the
enrollee, or the enrollee's provider of record must determine the
existence of a life-threatening condition on the basis that a prudent
layperson possessing an average knowledge of medicine and health would
believe that the enrollee's disease or condition is a life-threatening
condition.
(b) Appeal of adverse determination involving life-threatening
condition. Any party who receives an adverse determination involving
a life-threatening condition or whose appeal of an adverse determination
is denied by the URA may seek review of that determination or denial
by an IRO assigned under Insurance Code Chapter 4202 and Chapter 12
of this title (relating to Independent Review Organizations).
(c) Independent review involving life-threatening
and non-life-threatening conditions. A URA, or insurance carrier that
made the adverse determination, must notify TDI within one working
day from the date the request for an independent review is received.
The URA, or insurance carrier that made the adverse determination,
must submit the completed request for a review by an IRO form to TDI
through TDI's internet website.
(1) Assignment of IRO. TDI will, within one working
day of receipt of a complete request for independent review, randomly
assign an IRO to conduct an independent review and notify the URA,
payor, IRO, the enrollee or individual acting on behalf of the enrollee,
enrollee's provider of record, and any other providers listed by the
URA as having records relevant to the review of the assignment.
(2) Payor and URA compliance. The payor and URA must
comply with the IRO's determination with respect to the medical necessity,
appropriateness, or the experimental or investigational nature of
the health care items and services for an enrollee.
(3) Costs of independent review. The URA must pay for
the independent review and may recover costs associated with the independent
review from the payor.
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