| (a) The words and terms defined in Insurance Code Chapter
4201 have the same meaning when used in this subchapter, except as
otherwise provided by this subchapter, unless the context clearly
indicates otherwise.
(b) The following words and terms, when used in this
subchapter, have the following meanings, unless the context clearly
indicates otherwise.
(1) Adverse determination--A determination by a URA
made on behalf of any payor that the health care services provided
or proposed to be provided to an enrollee are not medically necessary
or appropriate or are experimental or investigational. The term does
not include a denial of health care services due to the failure to
request prospective or concurrent utilization review.
(2) Appeal--A URA's formal process by which an enrollee,
an individual acting on behalf of an enrollee, or an enrollee's provider
of record may request reconsideration of an adverse determination.
(3) Biographical affidavit--National Association of
Insurance Commissioners biographical affidavit to be used as an attachment
to the URA application.
(4) Certificate--A certificate issued by the commissioner
to an entity authorizing the entity to operate as a URA in the State
of Texas. A certificate is not issued to an insurance carrier or health
maintenance organization that is registered as a URA under §19.1704
of this title (relating to Certification or Registration of URAs).
(5) Commissioner--As defined in Insurance Code §31.001.
(6) Complaint--An oral or written expression of dissatisfaction
with a URA concerning the URA's process in conducting a utilization
review. The term "complaint" does not include:
(A) an expression of dissatisfaction constituting an
appeal under Insurance Code §4201.351; or
(B) a misunderstanding or misinformation that is resolved
promptly by supplying the appropriate information or by clearing up
the misunderstanding to the satisfaction of the complaining party.
(7) Concurrent utilization review--A form of utilization
review for ongoing health care or for an extension of treatment beyond
previously approved health care.
(8) Declination--A response to a request for verification
in which an HMO or preferred provider benefit plan does not issue
a verification for proposed medical care or health care services.
A declination is not necessarily a determination that a claim resulting
from the proposed services will not ultimately be paid.
(9) Disqualifying association--Any association that
may reasonably be perceived as having potential to influence the conduct
or decision of a reviewing physician, doctor, or other health care
provider, which may include:
(A) shared investment or ownership interest;
(B) contracts or agreements that provide incentives,
for example, referral fees, payments based on volume or value, or
waiver of beneficiary coinsurance and deductible amounts;
(C) contracts or agreements for space or equipment
rentals, personnel services, management contracts, referral services,
warranties, or any other services related to the management of a physician's,
doctor's, or other health care provider's practice;
(D) personal or family relationships; or
(E) any other financial arrangement that would require
disclosure under the Insurance Code or applicable TDI rules, or any
other association with the enrollee, employer, insurance carrier,
or HMO that may give the appearance of preventing the reviewing physician,
doctor, or other health care provider from rendering an unbiased
opinion.
(10) Doctor--A doctor of medicine, osteopathic medicine,
optometry, dentistry, podiatry, or chiropractic who is licensed and
authorized to practice.
(11) Experimental or investigational--A health care
treatment, service, or device for which there is early, developing
scientific or clinical evidence demonstrating the potential efficacy
of the treatment, service, or device, but that is not yet broadly
accepted as the prevailing standard of care.
(12) Health care facility--A hospital, emergency clinic,
outpatient clinic, or other facility providing health care.
(13) Health coverage--Payment for health care services
provided under a health benefit plan or a health insurance policy.
(14) Health maintenance organization or HMO--As defined
in Insurance Code §843.002.
(15) Insurance carrier or insurer--An entity authorized
and admitted to do the business of insurance in Texas under a certificate
of authority issued by TDI.
(16) Independent review organization or IRO--As defined
in §12.5 of this title (relating to Definitions).
(17) Legal holiday--
(A) a holiday as provided in Government Code §662.003(a);
(B) the Friday after Thanksgiving Day;
(C) December 24; and
(D) December 26.
(18) Medical records--The history of diagnosis and
treatment, including medical, mental health records as allowed by
law, dental, and other health care records from all disciplines providing
care to an enrollee.
(19) Mental health medical record summary--A summary
of process or progress notes relevant to understanding the enrollee's
need for treatment of a mental or emotional condition or disorder,
including:
(A) identifying information; and
(B) a treatment plan that includes a:
(i) diagnosis;
(ii) treatment intervention;
(iii) general characterization of enrollee behaviors
or thought processes that affect level of care needs; and
(iv) discharge plan.
(20) Mental health therapist--Any of the following
individuals who, in the ordinary course of business or professional
practice, as appropriate, diagnose, evaluate, or treat any mental
or emotional condition or disorder:
(A) an individual licensed by the Texas Medical Board
to practice medicine in this state;
(B) an individual licensed as a psychologist, a psychological
associate, or a specialist in school psychology by the Texas State
Board of Examiners of Psychologists;
(C) an individual licensed as a marriage and family
therapist by the Texas State Board of Examiners of Marriage and Family
Therapists;
(D) an individual licensed as a professional counselor
by the Texas State Board of Examiners of Professional Counselors;
(E) an individual licensed as a social worker by the
Texas State Board of Social Worker Examiners;
(F) an individual licensed as a physician assistant
by the Texas Medical Board;
(G) an individual licensed as a registered professional
nurse by the Texas Board of Nursing; or
(H) any other individual who is licensed or certified
by a state licensing board in the State of Texas, as appropriate,
to diagnose, evaluate, or treat any mental or emotional condition
or disorder.
(21) Mental or emotional condition or disorder--A
mental or emotional illness as detailed in the most current Diagnostic
and Statistical Manual of Mental Disorders.
(22) Person--Any individual, partnership, association,
corporation, organization, trust, hospital district, community mental
health center, mental retardation center, mental health and mental
retardation center, limited liability company, limited liability partnership,
the statewide rural health care system under Insurance Code Chapter
845, and any similar entity.
(23) Preauthorization--A form of prospective utilization
review by a payor or its URA of health care services proposed to be
provided to an enrollee.
(24) Preferred provider--
(A) with regard to a preferred provider benefit plan,
a preferred provider as defined in Insurance Code Chapter 1301.
(B) with regard to an HMO:
(i) a physician, as defined in Insurance Code §843.002(22),
who is a member of that HMO's delivery network; or
(ii) a provider, as defined in Insurance Code §843.002(24),
who is a member of that HMO's delivery network.
(25) Provider of record--The physician, doctor, or
other health care provider that has primary responsibility for the
health care services rendered or requested on behalf of the enrollee
or the physician, doctor, or other health care provider that has rendered
or has been requested to provide the health care services to the
enrollee. This definition includes any health care facility where
health care services are rendered on an inpatient or outpatient basis.
(26) Reasonable opportunity--At least one documented
good faith attempt to contact the provider of record that provides
an opportunity for the provider of record to discuss the services
under review with the URA during normal business hours prior to issuing
a prospective, concurrent, or retrospective utilization review adverse
determination:
(A) no less than one working day prior to issuing a
prospective utilization review adverse determination;
(B) no less than five working days prior to issuing
a retrospective utilization review adverse determination; or
(C) prior to issuing a concurrent or post-stabilization
review adverse determination.
(27) Registration--The process for a licensed insurance
carrier or HMO to register with TDI to perform utilization review
solely for its own enrollees.
(28) Request for a review by an IRO--Form to request
a review by an independent review organization that is completed by
the requesting party and submitted to the URA.
(29) Retrospective utilization review--A form of utilization
review for health care services that have been provided to an enrollee.
Retrospective utilization review does not include review of services
for which prospective or concurrent utilization reviews were previously
conducted or should have been previously conducted.
(30) Routine vision services--A routine annual or biennial
eye examination to determine ocular health and refractive conditions
that may include provision of glasses or contact lenses.
(31) Screening criteria--The written policies, decision
rules, medical protocols, or treatment guidelines used by the URA
as part of the utilization review process.
(32) TDI--The Texas Department of Insurance.
(33) URA--Utilization review agent.
(34) URA application--Form for application for, renewal
of, and reporting a material change to a certification or registration
as a URA in this state.
(35) Verification--A guarantee by an HMO or preferred
provider benefit plan that the HMO or preferred provider benefit plan
will pay for proposed medical care or health care services if the
services are rendered within the required timeframe to the enrollee
for whom the services are proposed. The term includes pre-certification,
certification, re-certification, and any other term that would be
a reliable representation by an HMO or preferred provider benefit
plan to a physician or provider if the request for the pre-certification,
certification, re-certification, or representation includes the requirements
of §19.1719 of this title (relating to Verification for Health
Maintenance Organizations and Preferred Provider Benefit Plans).
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