| (a) Review of utilization review plan. A utilization
review plan must be reviewed and approved by a physician and conducted
under standards developed and periodically updated with input from
both primary and specialty physicians, doctors, and other health care
providers, including practicing health care providers, as appropriate.
(b) Special circumstances. A utilization review determination
must be made in a manner that takes special circumstances of the case
into account that may require deviation from the norm stated in the
screening criteria or relevant guidelines. Special circumstances include,
but are not limited to, an individual who has a disability, acute
condition, or life-threatening illness. For the purposes of this section,
disability must not be construed to mean an injured employee who is
off work or receiving income benefits.
(c) Screening criteria. Each URA must utilize written
screening criteria that are evidence-based, scientifically valid,
outcome-focused, and that comply with the requirements in Insurance
Code §4201.153. The screening criteria must also recognize that
if evidence-based medicine is not available for a particular health
care service provided, the URA must utilize generally accepted standards
of medical practice recognized in the medical community. For workers'
compensation network coverage, screening criteria must comply with
Insurance Code Chapter 1305 and §10.101 of this title (relating
to General Standards for Utilization Review and Retrospective Review);
for workers' compensation non-network coverage and workers' compensation
health plan, screening criteria must comply with Labor Code §§401.011,
413.011, and 413.014, and Chapters 133, 134, and 137 of this title
(relating to General Medical Provisions; Benefits-Guidelines for Medical
Services, Charges, and Payments; and Disability Management, respectively).
(d) Referral and determination of adverse determinations.
Adverse determinations must be referred to and may only be determined
by a physician, doctor, or other health care provider with appropriate
credentials under Chapter 180 of this title (relating to Monitoring
and Enforcement) and §19.2006 of this title (relating to Requirements
and Prohibitions Relating to Personnel). Physicians and doctors performing
utilization review must also comply with Labor Code §§408.0043,
408.0044, and 408.0045.
(e) Delegation of review. A URA, including a specialty
URA, may delegate the utilization review to qualified personnel in
a hospital or other health care facility in which the health care
services to be reviewed were, or are, to be provided. The delegation
does not relieve the URA of full responsibility for compliance with
this subchapter, Insurance Code Chapter 4201, the Texas Workers' Compensation
Act, and applicable TDI-DWC rules, including responsibility for the
conduct of those to whom utilization review has been delegated.
(f) Complaint system. The URA must develop and implement
procedures for the resolution of oral or written complaints initiated
by injured employees, their representatives, or health care providers
concerning the utilization review. The URA must maintain records of
complaints for three years from the date the complaints are filed.
The complaints procedure must include a requirement for a written
response to the complainant by the agent within 30 calendar days.
The written response must include TDI's address, toll-free telephone
number, and a statement explaining that a complainant is entitled
to file a complaint with TDI.
(g) Compliance with Labor Code §504.055. Utilization
review plan written policies must evidence compliance with Labor Code §504.055,
concerning Expedited Provision of Medical Benefits for Certain Injuries
Sustained by First Responder in Course and Scope of Employment.
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