| (a) Qualification requirements. Physicians, doctors,
and other health care providers employed by or under contract with
a URA to perform utilization review must be appropriately trained,
qualified, and currently licensed. Personnel conducting utilization
review must hold an unrestricted license, an administrative license,
or be otherwise authorized to provide health care services by a licensing
agency in the United States.
(1) This subchapter does not supersede requirements
in the Medical Practice Act; Texas Medical Board rules; Texas Occupations
Code Chapter 201 (relating to Chiropractors); or Texas Board of Chiropractic
Examiners rules. Individuals licensed by the Texas Medical Board are
subject to 22 TAC Chapter 190, regarding disciplinary guidelines.
(2) Personnel who perform clerical or administrative
tasks are not required to have the qualifications prescribed by this
subsection.
(b) Disqualifying associations. For purposes of this
subsection, being employed by or under contract with the same URA
as the physician, doctor, or other health care provider who issued
the initial adverse determination does not in itself constitute a
disqualifying association. A physician, doctor, or health care provider
who conducts utilization review must not have any disqualifying associations
with the:
(1) enrollee or health care provider who is requesting
the utilization review or an appeal; or
(2) physician, doctor, or other health care provider
who issued the initial adverse determination.
(c) Information to be sent to TDI. The URA must send
to TDI the name, type, license number, state of licensure, and qualifications
of the personnel either employed or under contract to perform the
utilization review with an original or renewal application.
(d) Written procedures and maintenance of records.
URAs must develop and implement written procedures and maintain documentation
to demonstrate that all physicians, doctors, and other health care
providers used by the URA are licensed, qualified, and appropriately
trained or experienced.
(e) Training related to acquired brain injury treatment.
A URA must provide adequate training to personnel responsible for
precertification, certification, and recertification of services or
treatment relating to acquired brain injury in accord with Insurance
Code §1352.004. The purpose of the training is to prevent denial
of coverage in violation of Insurance Code §1352.003 and to avoid
confusion of medical benefits with mental health benefits.
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