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TITLE 28INSURANCE
PART 1TEXAS DEPARTMENT OF INSURANCE
CHAPTER 19LICENSING AND REGULATION OF INSURANCE PROFESSIONALS
SUBCHAPTER UUTILIZATION REVIEWS FOR HEALTH CARE PROVIDED UNDER WORKERS' COMPENSATION INSURANCE COVERAGE
RULE §19.2003Definitions

(a) The words and terms defined in Insurance Code Chapter 4201 have the same meaning when used in this subchapter, except as otherwise provided by this subchapter, unless the context clearly indicates otherwise.

(b) The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise.

  (1) Adverse determination--A determination by a URA made on behalf of a payor that the health care services provided or proposed to be provided to an injured employee are not medically necessary or appropriate. The term does not include a denial of health care services due to the failure to request prospective or concurrent utilization review. For the purposes of this subchapter, an adverse determination does not include a determination that health care services are experimental or investigational.

  (2) Appeal--The URA's formal process by which an injured employee, an injured employee's representative, or an injured employee's provider of record may request reconsideration of an adverse determination. For the purposes of this subchapter the term also applies to reconsideration processes prescribed by Labor Code Title 5 and applicable rules for workers' compensation.

  (3) Biographical affidavit--National Association of Insurance Commissioners biographical affidavit to be used as an attachment to the URA application.

  (4) Certificate--A certificate issued by the commissioner to an entity authorizing the entity to operate as a URA in the State of Texas. A certificate is not issued to an insurance carrier that is registered as a URA under §19.2004 of this title (relating to Certification or Registration of URAs).

  (5) Commissioner--As defined in Insurance Code §31.001.

  (6) Compensable injury--As defined in Labor Code §401.011.

  (7) Complaint--An oral or written expression of dissatisfaction with a URA concerning the URA's process in conducting a utilization review. The term "complaint" does not include:

    (A) an expression of dissatisfaction constituting an appeal under Insurance Code §4201.351; or

    (B) a misunderstanding or misinformation that is resolved promptly by supplying the appropriate information or by clearing up the misunderstanding to the satisfaction of the complaining party.

  (8) Concurrent utilization review--A form of utilization review for ongoing health care or for an extension of treatment beyond previously approved health care.

  (9) Disqualifying association--Any association that may reasonably be perceived as having potential to influence the conduct or decision of a reviewing physician, doctor, or other health care provider, which may include:

    (A) shared investment or ownership interest;

    (B) contracts or agreements that provide incentives, for example, referral fees, payments based on volume or value, or waiver of beneficiary coinsurance and deductible amounts;

    (C) contracts or agreements for space or equipment rentals, personnel services, management contracts, referral services, or warranties, or any other services related to the management of a physician's, doctor's, or other health care provider's practice;

    (D) personal or family relationships; or

    (E) any other financial arrangement that would require disclosure under Labor Code or applicable TDI-DWC rules, Insurance Code or applicable TDI rules, or any other association with the injured employee, employer, or insurance carrier that may give the appearance of preventing the reviewing physician, doctor, or other health care provider from rendering an unbiased opinion.

  (10) Doctor--As defined in Labor Code §401.011.

  (11) Experimental or investigational--A health care treatment, service, or device for which there is early, developing scientific or clinical evidence demonstrating the potential efficacy of the treatment, service, or device but that is not yet broadly accepted as the prevailing standard of care.

  (12) Health care--As defined in Labor Code §401.011.

  (13) Health care facility--As defined in Labor Code §401.011.

  (14) Insurance carrier or insurer--As defined in Labor Code §401.011.

  (15) Independent review organization or IRO--As defined in §12.5 of this title (relating to Definitions).

  (16) Legal holiday--

    (A) a holiday as provided in Government Code §662.003(a);

    (B) the Friday after Thanksgiving Day;

    (C) December 24; and

    (D) December 26.

  (17) Medical benefit--As defined in Labor Code §401.011.

  (18) Medical emergency--The sudden onset of a medical condition manifested by acute symptoms of sufficient severity, including severe pain that the absence of immediate medical attention could reasonably be expected to result in:

    (A) placing the injured employee's health or bodily functions in serious jeopardy; or

    (B) serious dysfunction of any body organ or part.

  (19) Medical records--The history of diagnosis of and treatment for an injury, including medical, mental health records as allowed by law, dental, and other health care records from all disciplines providing care to an injured employee.

  (20) Mental health medical record summary--A summary of process or progress notes relevant to understanding the injured employee's need for treatment of a mental or emotional condition or disorder including:

    (A) identifying information; and

    (B) a treatment plan that includes a:

      (i) diagnosis;

      (ii) treatment intervention;

      (iii) general characterization of injured employee behaviors or thought processes that affect level of care needs; and

      (iv) discharge plan.

  (21) Mental health therapist--Any of the following individuals who, in the ordinary course of business or professional practice, as appropriate, diagnose, evaluate, or treat any mental or emotional condition or disorder:

    (A) an individual licensed by the Texas Medical Board to practice medicine in this state;

    (B) an individual licensed as a psychologist, psychological associate, or a specialist in school psychology by the Texas State Board of Examiners of Psychologists;

    (C) an individual licensed as a marriage and family therapist by the Texas State Board of Examiners of Marriage and Family Therapists;

    (D) an individual licensed as a professional counselor by the Texas State Board of Examiners of Professional Counselors;

    (E) an individual licensed as a social worker by the Texas State Board of Social Worker Examiners;

    (F) an individual licensed as a physician assistant by the Texas Medical Board;

    (G) an individual licensed as a registered professional nurse by the Texas Board of Nursing; or

    (H) any other individual who is licensed or certified by a state licensing board in the State of Texas, as appropriate, to diagnose, evaluate, or treat any mental or emotional condition or disorder.

  (22) Mental or emotional condition or disorder--A mental or emotional illness as detailed in the most current Diagnostic and Statistical Manual of Mental Disorders.

  (23) Payor--Any person or entity that provides, offers to provide, or administers hospital, outpatient, medical, or other health benefits, including workers' compensation benefits, to an individual treated by a health care provider under a policy, plan, statute, or contract.

  (24) Peer review--An administrative review by a health care provider performed at the insurance carrier's request without a physical examination of the injured employee.

  (25) Person--Any individual, partnership, association, corporation, organization, trust, hospital district, community mental health center, mental retardation center, mental health and mental retardation center, limited liability company, limited liability partnership, a political subdivision of this state, the statewide rural health care system under Insurance Code Chapter 845, and any similar entity.

  (26) Preauthorization--A form of prospective utilization review by a payor or a payor's URA of health care services proposed to be provided to an injured employee.

  (27) Provider of record--The physician, doctor, or other health care provider that has primary responsibility for the health care services rendered or requested on behalf of an injured employee, or a physician, doctor, or other health care provider that has rendered or has been requested to provide health care services to an injured employee. This definition includes any health care facility where health care services are rendered on an inpatient or outpatient basis.

  (28) Reasonable opportunity--At least one documented good faith attempt to contact the provider of record that provides an opportunity for the provider of record to discuss the services under review with the URA during normal business hours prior to issuing a prospective, concurrent, or retrospective utilization review adverse determination:

    (A) no less than one working day prior to issuing a prospective utilization review adverse determination;

    (B) no less than five working days prior to issuing a retrospective utilization review adverse determination; or

    (C) prior to issuing a concurrent or post-stabilization review adverse determination.

  (29) Registration--The process for an insurance carrier to register with TDI to perform utilization review solely for injured employees covered by workers' compensation insurance coverage issued by the insurance carrier.

  (30) Request for a review by an IRO--Form to request a review by an independent review organization that is completed by the requesting party and submitted to the URA, or insurance carrier that made the adverse determination.

  (31) Retrospective utilization review--A form of utilization review for health care services that have been provided to an injured employee. Retrospective utilization review does not include review of services for which prospective or concurrent utilization reviews were previously conducted or should have been previously conducted.

  (32) Screening criteria--The written policies, decision rules, medical protocols, or treatment guidelines used by a URA as part of the utilization review process.

  (33) TDI--The Texas Department of Insurance.

  (34) TDI-DWC--The Texas Department of Insurance, Division of Workers' Compensation.

  (35) Texas Workers' Compensation Act--Labor Code Title 5, Subtitle A.

  (36) Treating doctor--As defined in Labor Code §401.011.

  (37) URA--Utilization review agent.

  (38) URA application--Form for application for, renewal of, and reporting a material change to a certification or registration as a URA in this state.

  (39) Workers' compensation health care network--As defined in Insurance Code §1305.004.

  (40) Workers' compensation health plan--Health care provided by a political subdivision contracting directly with health care providers or through a health benefits pool, under Labor Code §504.053(b)(2).

  (41) Workers' compensation insurance coverage--As defined in Labor Code §401.011.

  (42) Workers' compensation network coverage--Health care provided under a workers' compensation health care network.

  (43) Workers' compensation non-network coverage--Health care delivered under Labor Code Title 5, excluding health care provided under Insurance Code Chapter 1305.


Source Note: The provisions of this §19.2003 adopted to be effective February 20, 2013, 38 TexReg 892

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