|(a) Application. To be certified or registered as a
specialty URA, an applicant must submit to TDI the application, information,
and fee required in §19.2004 of this title (Certification or
Registration of URAs).
(b) Same specialty required. A specialty URA must conduct
utilization review under the direction of a health care provider who
is of the same specialty as the agent and who is licensed or otherwise
authorized to provide the specialty health care service by a state
licensing agency in the United States. To conduct utilization review,
a specialty URA must be of the same specialty as the health care provider
who ordered the service. For example, when conducting utilization
review of prescription drugs prescribed by a physician with a specialty
in neurological surgery, the specialty URA must be a physician with
a specialty in neurological surgery.
(c) Rule requirements. A specialty URA is subject to
the requirements of this subchapter, except for the following provisions:
(1) §19.2005(a) of this title (relating to General
Standards of Utilization Review);
(2) §19.2006(a), (c), (d), and (e) of this title
(relating to Requirements and Prohibitions Relating to Personnel);
(3) §19.2010 of this title (relating to Requirements
Prior to Issuing Adverse Determination); and
(4) §19.2011(a)(4) and (5) of this title (relating
to Written Procedures for Appeal of Adverse Determination).
(d) Utilization review plan. A specialty URA must have
its utilization review plan, including appeal requirements, reviewed
by a physician, doctor, or other health care provider of the appropriate
specialty, and the plan must be implemented under standards developed
with input from a physician, doctor, or other health care provider
of the appropriate specialty. The specialty URA must have written
procedures to ensure that these requirements are implemented.
(e) Requirements of employed or contracted physicians,
doctors, other health care providers, and personnel.
(1) Physicians, doctors, other health care providers,
and personnel employed by or under contract with a specialty URA to
perform workers' compensation utilization review must be appropriately
trained, qualified, and currently licensed as specified in Chapter
180 of this title (relating to Monitoring and Enforcement).
(2) Personnel conducting utilization review must hold
an unrestricted license, an administrative license issued by a state
licensing board in Texas, or be otherwise authorized to provide health
care services in Texas.
(f) Utilization review by a specialty URA. Utilization
review conducted by a specialty URA must be under the direction of
a physician, doctor, or other health care provider of the same specialty
and the physician, doctor, or other health care provider must be currently
licensed to provide the specialty health care service in Texas. The
physician, doctor, or other health care provider may be employed by
or under contract to the URA.
(g) Reasonable opportunity for discussion. In any instance
in which a specialty URA questions whether the health care is medically
necessary or appropriate, the health care provider that ordered the
services must, prior to the issuance of an adverse determination,
be afforded a reasonable opportunity to discuss the plan of treatment
for the patient and the clinical basis for the decision of the URA
with a health care provider of the same specialty as the URA. The
discussion must include, at a minimum, the clinical basis for the
specialty URA's decision and a description of documentation or evidence,
if any, that can be submitted by the provider of record that, on appeal,
might lead to a different utilization review decision.
(1) A specialty URA's telephone number must be provided
to the provider of record so that the provider of record may contact
the specialty URA to discuss the pending adverse determination.
(2) A specialty URA must maintain, and submit to TDI
or TDI-DWC on request, documentation that details the discussion opportunity
provided to the provider of record, including the date and time the
specialty URA offered the opportunity to discuss the adverse determination,
the date and time that the discussion, if any, took place, and the
discussion outcome. The specialty URA must allow the provider of record
five working days to respond orally or in writing.
(h) Appeal. The decision in an appeal of any adverse
determination by a specialty URA must be made by a physician or other
health care provider who has not previously reviewed the case and
who is of the same specialty as the specialty URA that made the adverse