| of the petition for judicial review to the division's
Chief Clerk of Proceedings. The division and the department are not
considered to be parties to the medical necessity dispute pursuant
to Labor Code §413.031(k-2) and §413.0311(e).
(G) Upon receipt of a court petition seeking judicial
review of a division CCH held under this subparagraph, the division
shall prepare and submit to the district court a certified copy of
the entire record of the division CCH under review.
(i) The following information must be included in the
petition or provided to the division by cover letter:
(I) any applicable division docket number for the dispute
being appealed;
(II) the names of the parties;
(III) the cause number;
(IV) the identity of the court; and
(V) the date the petition was filed with the court.
(ii) The record of the hearing includes:
(I) all pleadings, motions, and intermediate rulings;
(II) evidence received or considered;
(III) a statement of matters officially noticed;
(IV) questions and offers of proof, objections, and
rulings on them;
(V) any decision, opinion, report, or proposal for
decision by the officer presiding at the hearing and any decision
by the division; and
(VI) a transcription of the audio record of the division
CCH.
(iii) The division shall assess to the party seeking
judicial review expenses incurred by the division in preparing the
certified copy of the record, including transcription costs, in accordance
with the Government Code §2001.177 (relating to Costs of Preparing
Agency Record). Upon request, the division shall consider the financial
ability of the party to pay the costs, or any other factor that is
relevant to a just and reasonable assessment of costs.
(2) If a party to a medical necessity dispute properly
requests review of an IRO decision, the IRO, upon request, shall provide
a record of the review and submit it to the requestor within 15 days
of the request. The party requesting the record shall pay the IRO
copying costs for the records. The record shall include the following
documents that are in the possession of the IRO and which were reviewed
by the IRO in making the decision including:
(A) medical records;
(B) all documents used by the insurance carrier in
making the decision that resulted in the adverse determination under
review by the IRO;
(C) all documentation and written information submitted
by the insurance carrier to the IRO in support of the review;
(D) the written notification of the adverse determination
and the written determination of the appeal to the insurance carrier
or the insurance carrier's URA;
(E) a list containing the name, address, and phone
number of each health care provider who provided medical records to
the IRO relevant to the review;
(F) a list of all medical records or other documents
reviewed by the IRO, including the dates of those documents;
(G) a copy of the decision that was sent to all parties;
(H) copies of any pertinent medical literature or other
documentation (such as any treatment guideline or screening criteria)
utilized to support the decision or, where such documentation is subject
to copyright protection or is voluminous, then a listing of such documentation
referencing the portion(s) of each document utilized;
(I) a signed and certified custodian of records affidavit;
and
(J) other information that was required by the department
related to a request from an insurance carrier or the insurance carrier's
URA for the assignment of the IRO.
(t) Medical Fee Dispute Request. If the requestor has
an unresolved non-network fee dispute related to health care that
was found medically necessary, after the final decision of the medical
necessity dispute, the requestor may file a medical fee dispute in
accordance with §133.305 and §133.307 of this subchapter
(relating to MDR-General and MDR of Fee Disputes, respectively).
(u) In accordance with Labor Code §504.055(d),
an appeal regarding the denial of a claim for medical benefits, including
all health care required to cure or relieve the effects naturally
resulting from a compensable injury involving a first responder will
be accelerated by the division and given priority. The party seeking
to expedite the contested case hearing or appeal shall provide notice
to the division and independent review organization that the contested
case hearing or appeal involves a first responder.
(v) Enforcement. The department or the division may
initiate appropriate proceedings under Chapter 12 of this title or
Labor Code, Title 5 and division rules against an independent review
organization or a person conducting independent reviews.
|
| Source Note: The provisions of this §133.308 adopted to be effective December 31, 2006, 31 TexReg 10314; amended to be effective May 25, 2008, 33 TexReg 3954; amended to be effective May 31, 2012, 37 TexReg 3833 |
