| (1) The party or health care providers with relevant
records shall deliver the requested information to the IRO as directed
by the IRO. If the health care provider requested to submit records
is not a party to the dispute, the insurance carrier shall reimburse
copy expenses for the requested records pursuant to §134.120
of this title (relating to Reimbursement for Medical Documentation).
Parties to the dispute may not be reimbursed for copies of records
sent to the IRO.
(2) If the required documentation has not been received
as requested by the IRO, the IRO shall notify the department and the
department shall request the necessary documentation.
(3) Failure to provide the requested documentation
as directed by the IRO or department may result in enforcement action
as authorized by statutes and rules.
(m) Designated Doctor Exam. In performing a review
of medical necessity, an IRO may request that the division require
an examination by a designated doctor and direct the injured employee
to attend the examination pursuant to Labor Code §413.031(g)
and §408.0041. The IRO request to the division must be made no
later than 10 days after the IRO receives notification of assignment
of the IRO. The treating doctor and insurance carrier shall forward
a copy of all medical records, diagnostic reports, films, and other
medical documents to the designated doctor appointed by the division,
to arrive no later than three working days prior to the scheduled
examination. Communication with the designated doctor is prohibited
regarding issues not related to the medical necessity dispute. The
designated doctor shall complete a report and file it with the IRO,
in the form and manner prescribed by the division no later than seven
working days after completing the examination. The designated doctor
report shall address all issues as directed by the division.
(n) Time Frame for IRO Decision. The IRO will render
a decision as follows:
(1) for life-threatening conditions, no later than
eight days after the IRO receipt of the dispute;
(2) for preauthorization and concurrent medical necessity
disputes, no later than the 20th day after the IRO receipt of the
dispute;
(3) for retrospective medical necessity disputes, no
later than the 30th day after the IRO receipt of the IRO fee; and
(4) if a designated doctor examination has been requested
by the IRO, the above time frames begin on the date of the IRO receipt
of the designated doctor report.
(o) IRO Decision. The decision shall be mailed or otherwise
transmitted to the parties and to representatives of record for the
parties and transmitted in the form and manner prescribed by the department
within the time frames specified in this section.
(1) The IRO decision must include:
(A) a list of all medical records and other documents
reviewed by the IRO, including the dates of those documents;
(B) a description and the source of the screening criteria
or clinical basis used in making the decision;
(C) an analysis of, and explanation for, the decision,
including the findings and conclusions used to support the decision;
(D) a description of the qualifications of each physician
or other health care provider who reviewed the decision;
(E) a statement that clearly states whether or not
medical necessity exists for each of the health care services in dispute;
(F) a certification by the IRO that the reviewing health
care provider has no known conflicts of interest pursuant to the Insurance
Code Chapter 4202, Labor Code §413.032, and §12.203 of this
title; and
(G) if the IRO's decision is contrary to the division's
policies or guidelines adopted under Labor Code §413.011, the
IRO must indicate in the decision the specific basis for its divergence
in the review of medical necessity of non-network health care.
(2) The notification to the department shall also include
certification of the date and means by which the decision was sent
to the parties.
(p) Insurance Carrier Use of Peer Review Report after
an IRO Decision. If an IRO decision determines that medical necessity
exists for health care that the insurance carrier denied and the insurance
carrier utilized a peer review report on which to base its denial,
the peer review report shall not be used for subsequent medical necessity
denials of the same health care services subsequently reviewed for
that compensable injury.
(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.
Cont'd... |
