| (7) The request for medical dispute resolution does not contain all the components required by the TWCC-60 form and by subsection (e) or (f) of this section. The requestor may amend and resubmit the request to include all the required components as long as the amended request is filed within the timeframes required by subsection (d) of this section, and the request was not previously dismissed for lack of an IRO fee payment; or (8) The commission determines that good cause exists to dismiss the request. (j) TWCC Notification of Parties. The commission shall review the request for IRO review, assign an IRO with which no conflict of interest exists, and notify the parties and the IRO of the assignment, by a verifiable means of delivery. The commission will assign disputes on a rotating basis to the IROs certified by TDI, in accordance with Insurance Code article 21.58C and TDI rules. The commission may assign disputes in accordance with the priorities established in this rule and in a manner other than a rotating basis if necessary because of insufficient IRO capacity. (k) IRO Notification of Parties. The IRO shall also notify the parties of the assignment and require that documentation be sent directly to the assigned IRO and received not later than the seventh day after the party's receipt of the IRO notice. The documentation shall include: (1) Any medical records of the injured employee relevant to the review; (2) Any documents used by the utilization review agent or carrier in making the decision, to be reviewed by the IRO; and (3) Any supporting documentation submitted to the utilization review agent or carrier. (l) Confidentiality. No IRO or provider is required to obtain the written consent of the injured employee as a prerequisite to obtaining or releasing medical records relevant to the review in a workers' compensation medical dispute. The IRO shall preserve confidentiality of individual medical records as required by law. (m) Additional Information. The IRO may request additional relevant information from either party or from other providers whose records are relevant to the dispute, to review the medical issues in a dispute. The party shall deliver the requested information to the IRO as directed. The additional information must be received by the IRO within 14 days of receipt of the request for additional information. If the provider requested to submit records is not a party to the dispute, then copy expenses for the requested records shall be reimbursed by the carrier pursuant to §133.106 of this title (relating to Fair and Reasonable Fees for Required Reports and Records). Reimbursement for copies may not be permitted for a party to the dispute. (n) Designated Doctor Exam. In performing a review of medical necessity, an IRO may request that the commission order an examination by a designated doctor and order the employee to attend the examination. The IRO request to the commission must be made no later than 10 days after the IRO receives notification of assignment of the IRO. The treating doctor and carrier shall forward a copy of all medical records, diagnostic reports, films, and other medical documents to the designated doctor appointed by the commission, to arrive no later than three days prior to the scheduled examination. Communication with the designated doctor is prohibited regarding issues not related to the medical dispute. The designated doctor shall complete a report and file it with the IRO, on the form and in the manner prescribed by the commission, no later than seven working days after completing the examination. The designated doctor report shall address all issues the commission instructed the doctor to address. (o) Time Frame for IRO Decision. The IRO will review and render a decision on retrospective medical necessity disputes by the 30th day after the IRO receipt of the dispute. The IRO will review and render a decision on prospective necessity disputes by the 20th day after the IRO receipt of the dispute. If a designated doctor examination has been requested by the IRO, the above time frames begin from the date of the IRO receipt of the designated doctor report. (p) IRO Notification of Decision. (1) Notification of decision by the independent review organization must include: (A) the specific reasons, including the clinical basis, for decision; (B) a description and the source of the screening criteria that were utilized; (C) a description of the qualifications of the reviewing physician or provider; and (D) a certification by the IRO that the reviewing provider has certified that no known conflicts of interest exist between that provider and any of the treating providers or any of the providers who reviewed the case for decision prior to referral to the IRO. (2) The notification in a retrospective necessity dispute must be mailed or otherwise transmitted to the commission not later than the 30th day after the IRO receipt of the dispute. (3) The notification in a prospective necessity dispute must be delivered to the parties not later than the 20th day after the IRO receipt of the dispute. (4) The notification to the commission shall also include certification of the date and means by which the decision was sent to the parties. (5) An IRO decision is deemed to be a commission decision and order. (6) If an IRO decision finds that medical necessity exists for care that the carrier denied, and the carrier utilized the opinion of a peer review or other case review to issue its denial, the review and its rationale shall not be used on subsequent denials in that claim as the IRO has already found it unconvincing for the disputed health care. (q) Commission Posting. The commission shall post the IRO decision on the commission Internet website after confidential information has been redacted. (r) IRO Fees. IRO fees shall be paid as follows. (1) Upon receipt of an IRO assignment: (A) in a prospective dispute or an employee reimbursement dispute, the carrier shall remit payment to the assigned IRO at the same time the carrier files the documentation requested by the IRO; (B) in a retrospective dispute, the requestor shall remit payment to the assigned IRO at the same time the requestor files the documentation requested by the IRO; (2) Upon receipt of an IRO decision in a retrospective necessity dispute other than an employee reimbursement dispute, and in a concurrent review prospective necessity dispute, the commission shall review the decision to determine the prevailing party and, if applicable, will order the nonprevailing party to refund the IRO fee to the party who prevailed by CCH or SOAH decision. (A) If the IRO decision as to the main issue in dispute is a finding of medical necessity, the requestor is the prevailing party. (B) If the IRO decision does not find medical necessity with respect to the main issue in dispute, the respondent is the prevailing party. (C) if the IRO decision does not clearly determine the prevailing party, the commission shall determine the allowable fees for the health care in dispute, and the party who prevailed as to the majority of the fees for the disputed health care is the prevailing party. (3) The IRO shall bill copy expenses to the party liable for the independent review; provided, however, that no copy costs shall be paid to the requestor. (4) The injured employee shall not be required to pay any portion of the cost of a review. (5) Designated doctor examinations ordered by the commission at the request of an IRO, shall be paid by the party who is liable for the IRO fee in accordance with the appropriate fee guideline. (6) IRO fees will be paid in the same amounts as those set by TDI rules for tier one and tier two fees. In addition to the specialty classifications established as tier two fees in TDI rules, independent review by a doctor of chiropractic shall be paid the tier two fee. (7) If the fee has not been received by the IRO within 7 days of the party's receipt of notice from the IRO, the IRO shall notify the commission and the commission shall issue an order to pay the IRO fee. (8) Failure to pay or refund the IRO fee may result in enforcement action as allowable by statute and rules, removal from the commission Approved Doctor List, and/or restriction of future requests for independent review. (9) A party required to pay or refund the IRO fee to the other party is liable for that fee upon receipt of the order from the commission regardless of whether an appeal of the IRO decision has been or will be filed. (10) if the IRO decision is subsequently reversed or differently decided at a CCH or by a SOAH decision, the commission shall order a refund of the IRO fee to be paid the party who prevailed by CCH or SOAH decision within 10 days of receipt of the order. Cont'd... |
