| (a) The purpose of this section is to provide a prescribing
doctor or pharmacy an ability to obtain a medical interlocutory order
when preauthorization denials of previously prescribed and dispensed
drugs excluded from the closed formulary pose an unreasonable risk
of a medical emergency as defined in §134.500(7) of this title
(Definitions) and Insurance Code §1305.004(a)(13).
(b) A request for an interlocutory order that does
not meet the criteria described by this section may still be submitted
under §133.306 of this title (Interlocutory Orders for Medical
Benefits).
(c) A request for a medical interlocutory order must
contain the following information:
(1) injured employee name;
(2) date of birth of injured employee;
(3) prescribing doctor's name;
(4) name of drug and dosage;
(5) requester's name (pharmacy or prescribing doctor);
(6) requester's contact information;
(7) a statement that a preauthorization request for
a previously prescribed and dispensed drug, which is excluded from
the closed formulary, has been denied by the insurance carrier;
(8) a statement that an independent review request
has already been submitted to the insurance carrier or the insurance
carrier's utilization review agent under §133.308 of this title
(MDR of Medical Necessity Disputes);
(9) a statement that the preauthorization denial poses
an unreasonable risk of a medical emergency as defined in §134.500(7)
of this title;
(10) a statement that the potential medical emergency
has been documented in the preauthorization process;
(11) a statement that the insurance carrier has been
notified that a request for a medical interlocutory order is being
submitted to the division; and
(12) a signature and the following certification by
the medical interlocutory order requester for paragraphs (7) - (12)
of this subsection, "I hereby certify under penalty of law that the
previously listed conditions have been met."
(d) The division will process and approve a complete
request for a medical interlocutory order under this section. At its
discretion, the division may consider an incomplete request for a
medical interlocutory order.
(e) The request for a medical interlocutory order must
be in writing and must contain the information in subsection (c) of
this section. A convenient form that contains the required information
is on the division's website at https://www.tdi.texas.gov/forms/form20numeric.html.
(f) The requester must provide a copy of the request
to the insurance carrier, prescribing doctor, injured employee, and
dispensing pharmacy, if known, on the date the requester submits the
request to the division.
(g) An approved medical interlocutory order is effective
retroactively to the date the division received the complete request
for the medical interlocutory order.
(h) Notwithstanding §133.308 of this title:
(1) A request for reconsideration of a preauthorization
denial is not required prior to a request for independent review when
pursuing a medical interlocutory order under this section. If a request
for reconsideration or a medical interlocutory order request is not
initiated within 15 days from the initial preauthorization denial,
then the opportunity to request a medical interlocutory order under
this section does not apply.
(2) If pursuing a medical interlocutory order after
denial of a reconsideration request, a complete medical interlocutory
order must be submitted within five working days of the reconsideration
denial.
(i) An appeal of the independent review organization
(IRO) decision relating to the medical necessity and reasonableness
of the drugs contained in the medical interlocutory order must be
submitted under §133.308(t) of this title.
(j) The medical interlocutory order continues in effect
until the later of:
(1) final adjudication of a medical dispute about the
medical necessity and reasonableness of the drug contained in the
medical interlocutory order;
(2) expiration of the period for a timely appeal; or
(3) agreement of the parties.
(k) If a requester withdraws a request for medical
necessity dispute resolution, the requester accepts the preauthorization
denial.
(l) A party must comply with a medical interlocutory
order entered under this section, and the insurance carrier must reimburse
the pharmacy for prescriptions dispensed under a medical interlocutory
order.
(m) The insurance carrier must notify the prescribing
doctor, injured employee, and the dispensing pharmacy once reimbursement
is no longer required under subsection (j) of this section.
(n) Payments made by insurance carriers under this
section may be eligible for reimbursement from the subsequent injury
fund under Labor Code §§410.209 and 413.055 and applicable
rules.
(o) A decision issued by an IRO is not an agency or
commissioner decision.
(p) A party may seek to reverse or modify a medical
interlocutory order issued under this section if:
(1) a final determination of medical necessity has
been rendered; and
(2) the party requests a benefit contested case hearing
(CCH) from the division's chief clerk no later than 20 days after
the date the IRO decision is sent to the party. A benefit review conference
is not a prerequisite to a division CCH under this subsection. Except
as provided by this subsection, a division CCH must be conducted under
Chapters 140 and 142 of this title (Dispute Resolution--General Provisions
and Dispute Resolution--Benefit Contested Case Hearing).
(q) The insurance carrier may dispute an interlocutory
order entered under this title by filing a written request for a hearing
under Labor Code §413.055 and §148.3 of this title (Requesting
a Hearing).
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