| (a) If a URA must reimburse health care providers for
providing medical information under Insurance Code §4201.207,
reimbursement is limited to the reasonable costs for providing medical
records relevant to the utilization review that were requested by
the URA in writing. A health care provider's charge for providing
medical information to a URA must comply with §134.120 of this
title (relating to Reimbursement for Medical Documentation) and may
not include any costs that are recouped as a part of the charge for
health care.
(b) When conducting routine utilization review, the
URA must request all relevant and updated information and medical
records to complete the review.
(1) This information may include identifying information
about the enrollee; the benefit plan or claim; the treating physician,
doctor, or other health care provider; and the facilities rendering
care. It may also include clinical and diagnostic testing information
regarding the diagnoses of the enrollee and the medical history of
the enrollee relevant to the diagnoses; the enrollee's prognosis;
and the plan of treatment prescribed by the provider of record, along
with the provider of record's justification for the plan of treatment.
The required information should be obtained from the appropriate source.
(2) URAs must not routinely request copies of all medical
records on enrollees reviewed. During utilization review, copies of
the necessary or pertinent sections of medical records should only
be required when a difficulty develops in determining whether the
health care is medically necessary or appropriate, or experimental
or investigational.
(c) The URA must share among its various divisions
all clinical and demographic information on individual enrollees to
avoid duplicate requests for information from enrollees, physicians,
doctors, and other health care providers.
(d) A URA may not require as a condition of approval
of a health care service, or for any other reason, the observation
of a psychotherapy session or the submission or review of a mental
health therapist's process or progress notes that relate to the mental
health therapist's treatment of an enrollee's mental or emotional
condition or disorder. This prohibition extends to requiring an oral,
electronic, facsimile, or written submission or rendition of a mental
health therapist's process or progress notes. This prohibition does
not preclude the URA from requiring submission of:
(1) an enrollee's mental health medical record summary;
or
(2) medical records or process or progress notes that
relate to treatment of conditions or disorders other than a mental
or emotional condition or disorder.
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