| (4) if a designated doctor examination has been requested by the IRO, the above time frames begin on the date of the IRO receipt of the designated doctor report. (n) IRO Decision. The decision shall be mailed or otherwise transmitted to the parties and to representatives of record for the parties and transmitted in the form and manner prescribed by the Department within the time frames specified in this section. (1) The IRO decision must include: (A) a list of all medical records and other documents reviewed by the IRO, including the dates of those documents; (B) a description and the source of the screening criteria or clinical basis used in making the decision; (C) an analysis of, and explanation for, the decision, including the findings and conclusions used to support the decision; (D) a description of the qualifications of each physician or other health care provider who reviewed the decision; (E) a statement that clearly states whether or not medical necessity exists for each of the health care services in dispute; (F) a certification by the IRO that the reviewing provider has no known conflicts of interest pursuant to the Insurance Code Article 21.58A (Chapter 4201 effective April 1, 2007), Labor Code §413.032, and §12.203 of this title; and (G) if the IRO's decision is contrary to: (i) the Division's policies or guidelines adopted under Labor Code §413.011, the IRO must indicate in the decision the specific basis for its divergence in the review of medical necessity of non-network health care; or (ii) the network's treatment guidelines, the IRO must indicate in the decision the specific basis for its divergence in the review of medical necessity of network health care. (2) The notification to the Department shall also include certification of the date and means by which the decision was sent to the parties. (o) Carrier Use of Peer Review Report after an IRO Decision. If an IRO decision determines that medical necessity exists for health care that the carrier denied and the carrier utilized a peer review report on which to base its denial, the peer review report shall not be used for subsequent medical necessity denials of the same health care services subsequently reviewed for that compensable injury. (p) IRO Fees. IRO fees will be paid in the same amounts as the IRO fees set by Department rules. In addition to the specialty classifications established as tier two fees in Department rules, independent review by a doctor of chiropractic shall be paid the tier two fee. IRO fees shall be paid as follows: (1) In network disputes, a preauthorization, concurrent, or retrospective medical necessity dispute for health care provided by a network, the carrier must remit payment to the assigned IRO within 15 days after receipt of an invoice from the IRO; (2) In non-network disputes, IRO fees for disputes regarding nonnetwork health care must be paid as follows: (A) in a preauthorization or concurrent review medical necessity dispute or an employee reimbursement dispute, the carrier shall remit payment to the assigned IRO within 15 days after receipt of an invoice from the IRO. (B) in a retrospective medical necessity dispute, the requestor must remit payment to the assigned IRO within 15 days after receipt of an invoice from the IRO. (i) if the IRO fee has not been received within 15 days of the requestor's receipt of the invoice, the IRO shall notify the Department and the Department shall dismiss the dispute with prejudice. (ii) after an IRO decision is rendered, the IRO fee must be paid or refunded by the nonprevailing party as determined by the IRO in its decision. (3) Designated doctor examinations requested by an IRO shall be paid by the carrier in accordance with the medical fee guidelines under the Labor Code and related rules. (4) Failure to pay or refund the IRO fee may result in enforcement action as authorized by statute and rules and removal from the Division's Approved Doctor List. (5) For health care not provided by a network, the non-prevailing party to a retrospective medical necessity dispute must pay or refund the IRO fee to the prevailing party upon receipt of the IRO decision, but not later than 15 days regardless of whether an appeal of the IRO decision has been or will be filed. (6) The IRO fees may include an amended notification of decision if the Department determines the notification to be incomplete. The amended notification of decision shall be filed with the Department no later than five working days from the IRO's receipt of such notice from the Department. The amended notification of decision does not alter the deadlines for appeal. (7) If a requestor withdraws the request for an IRO decision after the IRO has been assigned by the Department but before the IRO sends the case to an IRO reviewer, the requestor shall pay the IRO a withdrawal fee of $150 within 30 days of the withdrawal. If a requestor withdraws the request for an IRO decision after the case is sent to a reviewer, the requestor shall pay the IRO the full IRO review fee within 30 days of the withdrawal. (8) In addition to Department enforcement action, the Division may assess an administrative fee in accordance with Labor Code §413.020 and §133.305 of this subchapter. (q) Defense. A carrier may claim a defense to a medical necessity dispute if the carrier timely complies with the IRO decision with respect to the medical necessity or appropriateness of health care for an employee. Upon receipt of an IRO decision for a retrospective medical necessity dispute that finds that medical necessity exists, the carrier must review, audit and process the bill. In addition, the carrier shall tender payment consistent with the IRO decision, and issue a new explanation of benefits (EOB) to reflect the payment within 21 days upon receipt of the IRO decision. (r) Appeal. A decision issued by an IRO is not considered an agency decision and neither the Department nor the Division are considered parties to an appeal. Appeals of IRO decisions will be as follows: (1) Non-Network Appeal Procedures. A carrier shall comply with the IRO decision in accordance with Labor Code §413.031(m). A party to a medical necessity dispute may seek judicial review of the IRO decision by filing a petition in a Travis County district court not later than the 30th day after the date on which the decision is received by the appealing party. The parties will be deemed to have received the decision on the acknowledgement date as defined in §102.5 of this title (relating to General Rules for Written Communications to and from the Commission). Any decision that is not timely appealed becomes final. A party to a medical necessity dispute who appeals the decision shall, at the time the petition is filed, send a copy of the petition for judicial review to the IRO that issued the decision being appealed, and request that the IRO provide a record for the appeal. The party requesting the record shall pay the IRO copying costs for the records. (2) Record for Non-Network Appeal. If a party to a medical necessity dispute files a petition for judicial review of the 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 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 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 carrier to the IRO in support of the review; (D) the written notification of the adverse determination and the written determination of the reconsideration; (E) a list containing the name, address and phone number of each 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 Cont'd... |
