| (26) Reasonable opportunity--At least one documented
good faith attempt to contact the provider of record that provides
an opportunity for the provider of record to discuss the services
under review with the URA during normal business hours prior to issuing
a prospective, concurrent, or retrospective utilization review adverse
determination:
(A) no less than one working day prior to issuing a
prospective utilization review adverse determination;
(B) no less than five working days prior to issuing
a retrospective utilization review adverse determination; or
(C) prior to issuing a concurrent or post-stabilization
review adverse determination.
(27) Registration--The process for a licensed insurance
carrier or HMO to register with TDI to perform utilization review
solely for its own enrollees.
(28) Request for a review by an IRO--Form to request
a review by an independent review organization that is completed by
the requesting party and submitted to the URA.
(29) Retrospective utilization review--A form of utilization
review for health care services that have been provided to an enrollee.
Retrospective utilization review does not include review of services
for which prospective or concurrent utilization reviews were previously
conducted or should have been previously conducted.
(30) Routine vision services--A routine annual or biennial
eye examination to determine ocular health and refractive conditions
that may include provision of glasses or contact lenses.
(31) Screening criteria--The written policies, decision
rules, medical protocols, or treatment guidelines used by the URA
as part of the utilization review process.
(32) TDI--The Texas Department of Insurance.
(33) URA--Utilization review agent.
(34) URA application--Form for application for, renewal
of, and reporting a material change to a certification or registration
as a URA in this state.
(35) Verification--A guarantee by an HMO or preferred
provider benefit plan that the HMO or preferred provider benefit plan
will pay for proposed medical care or health care services if the
services are rendered within the required timeframe to the enrollee
for whom the services are proposed. The term includes pre-certification,
certification, re-certification, and any other term that would be
a reliable representation by an HMO or preferred provider benefit
plan to a physician or provider if the request for the pre-certification,
certification, re-certification, or representation includes the requirements
of §19.1719 of this title (relating to Verification for Health
Maintenance Organizations and Preferred Provider Benefit Plans).
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