| (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 CCS 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 court, send a copy of the petition for
judicial review to the division's Chief Clerk of Proceedings. The
division and the department are not considered to be parties to the
medical necessity dispute pursuant to Labor Code §413.031(k-2)
and §413.0311(e).
(G) Upon receipt of a court petition seeking judicial
review of a division CCH held under this subparagraph, the division
shall prepare and submit to the district court a certified copy of
the entire record of the division CCH under review.
(i) The following information must be included in the
petition or provided to the division by cover letter:
(I) Any applicable division docket number for the dispute
being appealed;
(II) the names of the parties;
(III) the cause number;
(IV) the identity of the court; and
(V) the date the petition was filed with the court.
(ii) The record of the hearing includes:
(I) all pleadings, motions, and intermediate rulings;
(II) evidence received or considered;
(III) a statement of matters officially noticed;
(IV) questions and offers of proof, objections, and
rulings on them;
(V) any decision, opinion, report, or proposal for
decision by the officer presiding at the hearing and any decision
by the division; and
(VI) a transcription of the audio record of the division
CCH.
(iii) The division shall assess to the party seeking
judicial review expenses incurred by the division in preparing the
certified copy of the record, including transcription costs, in accordance
with the Government Code §2001.177 (relating to Costs of Preparing
Agency Record). Upon request, the division shall consider the financial
ability of the party to pay the costs, or any other factor that is
relevant to a just and reasonable assessment of costs.
(2) If a party to a medical necessity dispute properly
requests review of an IRO decision, the IRO, upon request, shall provide
a record of the review and submit it to the requestor within 15 days
of the request. The party requesting the record shall pay the IRO
copying costs for the records. The record shall include the following
documents that are in the possession of the IRO and which were reviewed
by the IRO in making the decision including:
(A) medical records;
(B) all documents used by the insurance carrier in
making the decision that resulted in the adverse determination under
review by the IRO;
(C) all documentation and written information submitted
by the insurance carrier to the IRO in support of the review;
(D) the written notification of the adverse determination
and the written determination of the appeal to the insurance carrier
or the insurance carrier's URA;
(E) a list containing the name, address, and phone
number of each health care provider who provided medical records to
the IRO relevant to the review;
(F) a list of all medical records of other documents
reviewed by the IRO, including the dates of those documents;
(G) a copy of the decision that was sent to all parties;
(H) copies of any pertinent medical literature or other
documentation (such as any treatment guideline or screening criteria)
utilized to support the decision or, where such documentation is subject
to copyright protection or is voluminous, then a listing of such documentation
referencing the portion(s) of each document utilized;
(I) a signed and certified custodian of records affidavit;
and
Cont'd... |
