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RULE §10.101General Standards for Utilization Review

(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.

Source Note: The provisions of this §10.101 adopted to be effective December 5, 2005, 30 TexReg 8099; amended to be effective August 2, 2022, 47 TexReg 4534

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