| (1) be of the same or similar licensure as the prescribing/referring or performing doctor; (2) have no known conflicts of interest with any of the providers known by the case review doctor to have examined, treated or reviewed records for the injured employee's injury claim; (3) not have previously treated or examined the injured employee within the past 12 months, nor have examined or treated the injured employee with regard to a medical condition being evaluated in the AMDR request; and (4) preserve the confidentiality of individual medical records as required by law. Written consent from the injured employee is not required for the case review doctor to obtain medical records relevant to the review. (i) Notification Order. (1) The commission, also within 10 days of receipt of a complete request for AMDR, shall issue written notification to the parties which: (A) indicates the case reviewer's name, license number, practice address, telephone number and fax number; (B) explains the purpose of the case review; (C) orders the requestor to pay the case review fee to the case review doctor no later than 14 days from the date of the order, unless the requestor is an injured employee, in which case the carrier is ordered to pay the case review fee; and (D) advises the carrier to forward a written response to the case review doctor. (2) The commission's notice to the carrier shall also include a copy of the AMDR request. The notice shall be forwarded to the carrier through its Austin representative. The carrier is deemed to have received the notification order and request for AMDR in accordance with §102.5(d) of this title (regarding General Rules for Written Communication to and from the Commission). (3) Once the notification order has been issued, withdrawals by any party are not permitted. (j) Case Review Fee. The AMDR case review fee is $100.00. (1) An injured employee is never liable for the AMDR case review fee. (2) The case review fee shall be initially paid by the requestor, unless the requestor is an injured employee, in which case the carrier pays the case review fee. Untimely payment of the case review fee will result in either: (A) a dismissal of the requestor's AMDR request; or (B) the issuance of an order to the carrier requiring payment of the case review fee when the requestor is an injured employee. (3) Final liability for the AMDR case review fee shall be determined as provided in subsection (n) of this section. (k) Carrier Response. No later than 14 days from the date of the notification order, the carrier shall submit directly to the case review doctor: (1) the $100.00 case review fee with an annotation identifying the case review number, when required; and (2) a written response by facsimile or electronic transmission, either explaining why the disputed health care is not medically necessary, or indicating that no documentation will be submitted for review. The response shall be limited to a maximum of five single-sided documents, which may include a summary, supporting the carrier's position. The carrier may elect to provide this written response. If the carrier elects to not provide a written response, the AMDR process will proceed to a final decision and order. (l) Case Review. The case review doctor shall review up to five single-sided documents provided by each party. (1) If a party's documentation exceeds the limit of a maximum of five single-sided documents, the case review doctor shall not review any of the offending party's documentation and the case review doctor shall indicate this in the report. (2) If the case review doctor does not receive a timely response from the carrier, the case review doctor shall proceed with the review and issue the report required by subsection (m) of this section. (3) To avoid undue influence on the case review doctor, any communication regarding the AMDR dispute between a party and the case review doctor, before, during, or after the review, is prohibited. (4) Upon completion of the case review, the case review doctor shall maintain a copy of the report, all documentation submitted by the parties, the date the documentation was received and from whom, and the date and time the report was issued to, and received by, all parties. The case review doctor shall forward to the commission, upon request, copies of the retained information. (m) Report. No later than five days after the date the carrier's response was due, the case review doctor shall issue a report addressing the medical necessity of the disputed health care. (1) The report must include: (A) the specific reasons for the case review doctor's determination, including the clinical basis for the decision; (B) a description of, and the source of, the screening criteria that were utilized; (C) a description of the qualifications of the case review doctor; and (D) a certification by the case review doctor that no known conflicts of interest exist with any of the providers known by the case review doctor to have examined, treated or reviewed records for the injured employee's injury claim. The certification must also include a statement that the case review doctor has not previously treated or examined the injured employee within the past 12 months, nor has the case review doctor examined or treated the injured employee with regard to a medical condition being evaluated in the AMDR request. (2) The case review doctor shall forward the completed report and a copy of the reviewed carrier's response to all parties and the commission. (A) This information shall be forwarded to all parties and the commission by facsimile or electronic transmission. (B) If the party is an injured employee and a facsimile number has not been provided, this information shall be provided by other verifiable means. (3) Requests for clarification from the parties will not be accepted by the commission or the case review doctor. The commission, at its discretion, may seek clarification from the case review doctor and may require the case review doctor to issue an amended report within three days of the commission's request. (n) Final Decision and Order. The case review doctor's report is deemed to be a commission decision and order, and is effective the date signed by the case review doctor. (1) The decision and order is final and is not subject to further review. (2) If the decision and order indicates that none of the disputed care was medically necessary, the decision and order will direct the prescribing/referring doctor to reimburse the requestor the case review fee only if the requestor is a pharmacy or durable medical equipment provider. No other parties shall reimburse, or be entitled to reimbursement of, the case review fee. (3) If the decision and order indicates that any of the disputed care was medically necessary it will include an order that the carrier pay, in accordance with the commission's fee guidelines, for the care that was determined by the case review doctor to be medically necessary. The carrier will also be ordered to reimburse the requestor the case review fee. (4) A party shall comply with the decision and order within 20 days of receipt. (5) This final decision and order shall not be used by a carrier to prospectively deny future medical care. (o) Dismissal. The commission may dismiss a request for AMDR if the commission determines that good cause exists. |
