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RULE §19.1711Written Procedures for Appeal of Adverse Determinations

(a) Appeal of prospective or concurrent review adverse determinations. Each URA must comply with its written procedures for appeals. The written procedures for appeals must comply with Insurance Code Chapter 4201, Subchapter H, concerning Appeal of Adverse Determination, and must include provisions that specify the following:

  (1) Time frames for filing the written or oral appeal, which may not be less than 30 calendar days after the date of issuance of written notification of an adverse determination.

  (2) An enrollee, an individual acting on behalf of the enrollee, or the provider of record may appeal the adverse determination orally or in writing.

  (3) An appeal acknowledgement letter must:

    (A) be sent to the appealing party within five working days from receipt of the appeal;

    (B) acknowledge the date the URA received the appeal;

    (C) include a list of relevant documents that must be submitted by the appealing party to the URA; and

    (D) include a one-page appeal form to be filled out by the appealing party when the URA receives an oral appeal of an adverse determination.

  (4) Appeal decisions must be made by a physician who has not previously reviewed the case.

  (5) In any instance in which the URA is questioning the medical necessity, the appropriateness, or the experimental or investigational nature, of the health care services prior to issuance of adverse determination, the URA must afford the provider of record a reasonable opportunity to discuss the plan of treatment for the enrollee with a physician. The provision must require that the discussion include, at a minimum, the clinical basis for the URA's decision.

  (6) If an appeal is requested or denied and, within 10 working days from the request or denial, the health care provider requests a particular type of specialty provider review the case, the appeal or the decision denying the appeal must be reviewed by a health care provider in the same or similar specialty that typically manages the medical, dental, or specialty condition, procedure, or treatment under discussion for review of the adverse determination. The specialty review must be completed within 15 working days of receipt of the request. The provision must state that notification of the appeal under this paragraph must be in writing.

  (7) In addition to the written appeal, a method for expedited appeals is available for denials of emergency care, continued stays for hospitalized enrollees, or prescription drugs or intravenous infusions for which an enrollee is receiving benefits under the health insurance policy; adverse determinations of a step-therapy protocol exception request under Insurance Code §1369.0546; or a denial of another service if the requesting health care provider includes a written statement with supporting documentation that the service is necessary to treat a life-threatening condition or prevent serious harm to the patient. The provision must state that:

    (A) the procedure must include a review by a health care provider who has not previously reviewed the case and who is of the same or a similar specialty as the health care provider that typically manages the medical condition, procedure, or treatment under review;

    (B) an expedited appeal must be completed based on the immediacy of the medical or dental condition, procedure, or treatment, but may in no event exceed one working day from the date all information necessary to complete the appeal is received; and

    (C) an expedited appeal determination may be provided by telephone or electronic transmission but must be followed with a letter within three working days of the initial telephonic or electronic notification.

  (8) After the URA has sought review of the appeal of the adverse determination, the URA must issue a response letter to the enrollee or an individual acting on behalf of the enrollee, and the provider of record, explaining the resolution of the appeal. If there is an adverse determination of the appeal, the letter must include:

    (A) a statement of the specific medical, dental, or contractual reasons for the resolution;

    (B) the clinical basis for the decision;

    (C) a description of or the source of the screening criteria that were utilized in making the determination;

    (D) the professional specialty of the physician who made the determination;

    (E) notice of the appealing party's right to seek review of the adverse determination by an IRO under §19.1717 of this title (relating to Independent Review of Adverse Determinations);

    (F) notice of the independent review process;

    (G) a copy of a request for a review by an IRO form; and

    (H) procedures for filing a complaint as described in §19.1705(f) of this title (relating to General Standards of Utilization Review).

  (9) A statement that the appeal must be resolved as soon as practical, but, under Insurance Code §4201.359 and §1352.006, in no case later than 30 calendar days after the date the URA receives the appeal from the appealing party referenced under paragraph (3) of this subsection.

  (10) In a circumstance involving an enrollee's life-threatening condition or the denial of prescription drugs or intravenous infusions for which the enrollee is receiving benefits under the health insurance policy, the enrollee is entitled to an immediate appeal to an IRO and is not required to comply with procedures for an appeal of the URA's adverse determination.

(b) Appeal of retrospective review adverse determinations. A URA must maintain and make available a written description of the appeal procedures involving an adverse determination in a retrospective review. The written procedures for appeals must specify that an enrollee, an individual acting on behalf of the enrollee, or the provider of record may appeal the adverse determination orally or in writing. The appeal procedures must comply with:

  (1) Chapter 21, Subchapter T, of this title (relating to Submission of Clean Claims), if applicable;

  (2) Section 19.1709 of this title (relating to Notice of Determinations Made in Utilization Review), for retrospective utilization review adverse determination appeals; and

  (3) Insurance Code §4201.359.

(c) Appeals concerning an acquired brain injury. A URA must comply with this subsection in regard to a determination concerning an acquired brain injury as defined by §21.3102 of this title (relating to Definitions). Not later than three business days after the date on which an individual requests utilization review or requests an extension of coverage based on medical necessity or appropriateness, a URA must provide notification of the determination through a direct telephone contact to the individual making the request. This subsection does not apply to a determination made for coverage under a small employer health benefit plan.

Source Note: The provisions of this §19.1711 adopted to be effective February 20, 2013, 38 TexReg 892; amended to be effective July 28, 2019, 44 TexReg 3907; amended to be effective March 17, 2021, 46 TexReg 1647

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