| (H) any other medical or scientific evidence that is
comparable to the sources listed in subparagraphs (A) - (F) of this
paragraph.
(26) Nurse--A registered or professional nurse, a licensed
vocational nurse, or a licensed practical nurse.
(27) Patient--The enrollee or an eligible dependent
of the enrollee under a health benefit plan or health insurance policy,
or an injured employee entitled to receive workers' compensation benefits
under Labor Code Title 5.
(28) Payor--
(A) an insurer that writes health insurance policies;
(B) a preferred provider organization, health maintenance
organization, or self-insurance plan; or
(C) any other person or entity that provides, offers
to provide, or administers hospital, outpatient, medical, or other
health benefits, including workers' compensation benefits as provided
under Insurance Code §4201.054, to persons treated by a health
care provider in this state under a policy, plan, or contract.
(29) Person--An individual, corporation, partnership,
association, joint-stock company, trust, unincorporated organization,
any similar entity, or any combination acting in concert.
(30) Physical address--Location of the IRO's primary
office where personnel are reasonably available by telephone at least
40 hours per week during normal business hours in both Central and
Mountain time zones to discuss or respond to requests for independent
review.
(31) Physician--A licensed doctor of medicine or a
doctor of osteopathy.
(32) Primary office--The place where an IRO maintains
its physical address in Texas, and where its books and records about
independent reviews assigned by the department are maintained and
accessible.
(33) Provider of record--The physician or other health
care provider that has primary responsibility for the care, treatment,
and services rendered or requested on behalf of the patient; or the
physician or health care provider that has rendered or has been requested
to provide the care, treatment, or services to the patient. This definition
includes any health care facility where treatment is rendered on an
inpatient or outpatient basis.
(34) Randomized clinical trial--A controlled, prospective
study of patients who have been randomized into an experimental group
and a control group at the beginning of the study with only the experimental
group of patients receiving a specific intervention, which includes
study of the groups for variables and anticipated outcomes over time.
(35) Review criteria--The written policies, medical
protocols, previous decisions, and guidelines used by the IRO to make
decisions about the medical necessity or appropriateness of a treatment,
procedure, or service or the experimental or investigational nature
of a treatment, procedure, or service.
(36) TDI-DWC--The Texas Department of Insurance, Division
of Workers' Compensation.
(37) Utilization review agent--A person holding a certificate
under Insurance Code Chapter 4201.
(38) Working day--A weekday that is not a legal holiday.
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| Source Note: The provisions of this §12.5 adopted to be effective November 26, 1997, 22 TexReg 11363; amended to be effective December 26, 2010, 35 TexReg 11281; amended to be effective July 7, 2015, 40 TexReg 2538 |
