| (q) 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 insurance 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 non-network health care must be paid as follows:
(A) in a preauthorization or concurrent review medical
necessity dispute or retrospective medical necessity dispute resolution
when reimbursement was denied for health care paid by the injured
employee, the insurance 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 insurance 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.
(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.
(9) This section shall not be deemed to require an
employee to pay for any part of a review. If application of a provision
of this section would require an employee to pay for part of the cost
of a review, that cost shall instead be paid by the insurance carrier.
(r) Defense. An insurance carrier may claim a defense
to a medical necessity dispute if the insurance carrier timely complies
with the IRO decision with respect to the medical necessity or appropriateness
of health care for an injured employee. Upon receipt of an IRO decision
for a retrospective medical necessity dispute that finds that medical
necessity exists, the insurance carrier must review, audit, and process
the bill. In addition, the insurance 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. The decision of an IRO under Labor Code §413.031(m)
is binding during the pendency of a dispute.
(s) Appeal of IRO decision. A decision issued by an
IRO is not considered an agency decision and neither the department
nor the division is considered a party to an appeal. In a division
Contested Case Hearing (CCH), the party appealing the IRO decision
has the burden of overcoming the decision issued by an IRO by a preponderance
of evidence based medical evidence. A party to a medical dispute that
remains unresolved after a review under Labor Code §504.053(d)(3)
or Insurance Code §1305.355 is entitled to a contested case hearing
in the same manner as a hearing conducted under Labor Code §413.0311.
A party to a medical necessity dispute may seek review of a dismissal
or decision at a division CCH as follows:
(1) A party to a medical necessity dispute may appeal
the IRO decision by requesting a division CCH conducted by a division
administrative law judge. A benefit review conference is not a prerequisite
to a division CCH under this subsection.
(A) The written appeal must be filed with the division's
Chief Clerk of Proceedings no later than the later of the 20th day
after the effective date of this section or 20 days after the date
the IRO decision is sent to the appealing party and must be filed
in the form and manner required by the division. Requests that are
timely submitted to a division location other than the division's
Chief Clerk of Proceedings, such as a local field office of the division,
will be considered timely filed and forwarded to the Chief Clerk of
Proceedings for processing; however, this may result in a delay in
the processing of the request.
(B) The party appealing the IRO decision shall send
a copy of its written request for a hearing to all other parties involved
in the dispute. The IRO is not required to participate in the division
CCH or any appeal.
(C) Except as otherwise provided in this section, a
division CCH shall be conducted in accordance with Chapters 140 and
142 of this title (relating to Dispute Resolution--General Provisions
and Dispute Resolution--Benefit Contested Case Hearing).
(D) At a division CCH, the administrative law judge
shall consider the treatment guidelines:
(i) adopted by the network under Insurance Code §1305.304,
for a network dispute;
(ii) adopted by the division under Labor Code §413.011(e)
for a non-network dispute; or
(iii) adopted, if any, by the political subdivision
or pool that provides medical benefits under Labor Code §504.053(b)(2)
if those treatment guidelines meet the standards provided by Labor
Code §413.011(e).
(E) Prior to a division CCH, a party may submit a request
for a letter of clarification by the IRO to the division's Chief Clerk
of Proceedings. A copy of the request for a letter of clarification
must be provided to all parties involved in the dispute at the time
it is submitted to the division.
(i) A party's request for a letter of clarification
must be submitted to the division no later than 10 days before the
date set for hearing. The request must include a cover letter that
contains the names of the parties and all identification numbers assigned
to the hearing or the independent review by the division, the department,
or the IRO.
(ii) The department may at its discretion forward the
party's request for a letter of clarification to the IRO that conducted
the independent review. The department will not forward to the IRO
a request for a letter of clarification that asks the IRO to reconsider
its decision or issue a new decision.
(iii) The IRO shall send a response to the request
for a letter of clarification to the department and to all parties
that received a copy of the IRO's decision within 5 days of receipt
of the party's request for a letter of clarification. The IRO's response
is limited to clarifying statements in its original decision; the
IRO shall not reconsider its decision and shall not issue a new decision
in response to a request for a letter of clarification.
(iv) A request for a letter of clarification does not
alter the deadlines for appeal.
(F) A party to a medical necessity dispute who has
exhausted all administrative remedies may seek judicial review of
the division's decision. Judicial review under this paragraph shall
be conducted in the manner provided for judicial review of contested
cases under Chapter 2001, Subchapter G Government Code, and is governed
by the substantial evidence rule. The party seeking judicial review
under this section must file suit not later than the 45th day after
the date on which the division mailed the party the decision of the
administrative law judge. The mailing date is considered to be the
fifth day after the date the decision of the administrative law judge
was filed with the division. A decision becomes final and appealable
when issued by a division administrative law judge. If a party to
a medical necessity dispute files a petition for judicial review of
the division's decision, the party shall, at the time the petition
is filed with the district Cont'd... |
