| (a) Appeal of prospective or concurrent review adverse
determinations. Each URA must comply with its written procedures for
appeals. The written procedures for appeals must comply with Insurance
Code Chapter 4201, Subchapter H, concerning Appeal of Adverse Determination,
and must include the following provisions:
(1) For workers' compensation network coverage, a URA
must include in its written procedures a statement specifying the
timeframes for requesting the appeal under Insurance Code §1305.354,
which may not be less than 30 calendar days after the date of issuance
of written notification of an adverse determination.
(2) For workers' compensation non-network coverage
and workers' compensation health plans, a URA must include in its
written procedures a statement specifying that the timeframes for
requesting the appeal of the adverse determination must be consistent
with §134.600 of this title (relating to Preauthorization, Concurrent
Review, and Voluntary Certification of Health Care) and Chapter 133,
Subchapter D, of this title (relating to Dispute of Medical Bills).
(3) An injured employee, the injured employee's representative,
or the provider of record may appeal the adverse determination orally
or in writing.
(4) Appeal decisions must be made by a physician, dentist,
or chiropractor who has not previously reviewed the case, as required
by Chapter 180 of this title (relating to Monitoring and Enforcement);
Insurance Code §1305.354; and §10.103 of this title (relating
to Reconsideration of Adverse Determination). If the health care services
in question are dental services, then a dentist may make the appeal
decision if the services in question are within the scope of the dentist's
license to practice dentistry. If the health care services in question
are chiropractic services, then a chiropractor may make the appeal
decision if the services in question are within the scope of the chiropractor's
license to practice chiropractic.
(5) Subject to the notice requirements of §19.2009
of this title (relating to Notice of Determinations Made in Utilization
Review), in any instance in which the URA is questioning the medical
necessity or appropriateness of the health care services, prior to
issuance of an adverse determination, the URA must afford the provider
of record a reasonable opportunity to discuss the plan of treatment
for the injured employee with a physician. If the health care services
in question are dental services, then a dentist may conduct the discussion
if the services in question are within the scope of the dentist's
license to practice dentistry. If the health care services in question
are chiropractic services, then a chiropractor may conduct the discussion
if the services in question are within the scope of the chiropractor's
license to practice chiropractic. The provision must state that the
discussion must include, at a minimum, the clinical basis for the
URA's decision.
(6) After the URA has sought review of the appeal of
the adverse determination, the URA must issue a response letter explaining
the resolution of the appeal to individuals specified in §19.2009(a)
of this title (relating to Notice of Determinations Made in Utilization
Review).
(7) The response letter required in paragraph (6) of
this subsection, for both workers' compensation network coverage and
for workers' compensation non-network coverage, must include:
(A) a statement of the specific medical or dental reasons
for the resolution;
(B) the clinical basis for the decision;
(C) the professional specialty and Texas license number
of the physician, dentist, or chiropractor who made the determination;
(D) notice of the appealing party's right to seek review
of the adverse determination by an IRO under §19.2017 of this
title (relating to Independent Review of Adverse Determinations),
the notice of the independent review process, and either of the following:
(i) a copy of the request for a review by an IRO form,
available at www.tdi.texas.gov/forms; or
(ii) notice in at least 12 point font that the injured
employee can obtain a copy of the request for a review by an IRO form
by:
(I) accessing TDI's website, at www.tdi.texas.gov/forms;
or
(II) calling {insert URA's telephone number} to request
a copy of the form, at which time the URA will send a copy of the
request for a review by an IRO form to the injured employee or health
care provider;
(E) procedures for filing a complaint as described
in §19.2005(f) of this title (relating to General Standards of
Utilization Review);
(F) for workers' compensation network coverage only,
a description or the source of the screening criteria that were utilized
in making the determination, including a description of the network
adopted treatment guidelines, if any; and
(G) for workers' compensation non-network coverage
only, a description of treatment guidelines utilized under Chapter
137 of this title (relating to Disability Management) or Labor Code §504.054(b)
in making a determination;
(8) Timeframes required for written notifications to
the appealing party of the determination of the appeal:
(A) must be resolved as specified in §10.103 of
this title for workers' compensation network coverage; and
(B) must be resolved as specified in §134.600
of this title for workers' compensation non-network coverage.
(9) In a circumstance involving an injured employee's
life-threatening condition, or involving a request for a medical interlocutory
order under §134.550 of this title (Medical Interlocutory Order),
the injured employee is entitled to an immediate review by an IRO
of the adverse determination and is not required to comply with procedures
for an appeal of the adverse determination by the URA.
(b) Appeal of retrospective review adverse determinations.
A URA must maintain and make available a written description of appeal
procedures involving an adverse determination in a retrospective review.
The appeal procedures must comply with §19.2009 of this title
for retrospective utilization review adverse determination appeals
and Insurance Code §4201.359. The written procedures for appeals
must specify that an injured employee, the injured employee's representative,
or the provider of record may appeal the adverse determination orally
or in writing.
(1) Workers' compensation network coverage. For workers'
compensation network coverage, appeal procedures must comply with
the requirements in Insurance Code Chapter 1305, §10.102 of this
title (relating to Notice of Certain Utilization Review Determinations;
Preauthorization and Retrospective Review Requirements), and §133.250
of this title (relating to Reconsideration for Payment of Medical
Bills).
(2) Workers' compensation non-network coverage. For
workers' compensation non-network coverage, the appeal procedures
must comply with the requirements of §133.250 of this title.
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