| (a) Screening criteria used for utilization review
related to a workers' compensation health care network must be consistent
with the network's treatment guidelines, return-to-work guidelines,
and individual treatment protocols.
(b) The carrier's utilization review program must include
a process for a treating doctor or specialist to request approval
from the network for deviation from the treatment guidelines, return-to-work
guidelines, and individual treatment protocols where required by the
particular circumstances of an employee's injury.
(c) Under Insurance Code §4201.152, concerning
Utilization Review Under Physician, a network that uses doctors to
perform reviews of health care services provided under this chapter,
including utilization review, or peer reviews under Labor Code §408.0231(a),
concerning Maintenance of List of Approved Doctors; Sanctions and
Privileges Relating to Health Care, may only use doctors licensed
to practice in this state.
(d) Physicians and doctors conducting utilization review
must hold a professional certification in a health care specialty
appropriate to the type of health care the injured employee is receiving
as required by Labor Code §§408.0043 - 408.0045, concerning
Professional Specialty Certification Required for Certain Review,
Review of Dental Services, and Review of Chiropractic Services. Physicians,
doctors, and other health care providers conducting utilization review
must have the appropriate credentials as required by Chapter 180 of
this title (relating to Monitoring and Enforcement).
(e) The preauthorization requirements of Labor Code §413.014,
concerning Preauthorization Requirements; Concurrent Review and Certification
of Health Care, and rules adopted under that section do not apply
to health care provided through a workers' compensation network. If
a carrier or network uses a preauthorization process within a network,
the requirements of Insurance Code Chapter 1305, Subchapter H, concerning
Utilization Review, and this chapter apply.
(f) Insurance Code Chapter 1305, Subchapter H, and
applicable network requirements in Chapter 19, Subchapter U, of this
title (relating to Utilization Reviews for Health Care Provided Under
Workers' Compensation Insurance Coverage), apply to utilization review
for health care provided through a workers' compensation network that
is conducted by insurance carriers, utilization review agents, and
networks that perform utilization review for or on behalf of insurance
carriers and utilization review agents.
(g) In addition to the requirements in subsection (f)
of this section, the reconsideration procedures must include a method
for expedited reconsideration procedures in accordance with Insurance
Code §1305.354(b) and (c), concerning Reconsideration of Adverse
Determination.
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