(a) The following words and terms when used in this
chapter shall have the following meanings, unless the context clearly
indicates otherwise:
(1) Adverse determination: A determination by a utilization
review agent made on behalf of a payor that the health care services
provided or proposed to be provided to an injured employee are not
medically necessary or appropriate. The term does not include a denial
of health care services due to the failure to request prospective
or concurrent utilization review. An adverse determination does not
include a determination that health care services are experimental
or investigational.
(2) Ambulatory surgical services: surgical services
provided in a facility that operates primarily to provide surgical
services to patients who do not require overnight hospital care.
(3) Concurrent utilization review: a form of utilization
review for on-going health care listed in subsection (q) of this section
for an extension of treatment beyond previously approved health care
listed in subsection (p) of this section.
(4) Diagnostic study: any test used to help establish
or exclude the presence of disease/injury in symptomatic individuals.
The test may help determine the diagnosis, screen for specific disease/injury,
guide the management of an established disease/injury, and formulate
a prognosis.
(5) Final adjudication: the commissioner has issued
a final decision or order that is no longer subject to appeal by either
party.
(6) Outpatient surgical services: surgical services
provided in a freestanding surgical center or a hospital outpatient
department to patients who do not require overnight hospital care.
(7) Preauthorization: a form of prospective utilization
review by a payor or a payor's utilization review agent of health
care services proposed to be provided to an injured employee.
(8) 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 utilization review agent 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.
(9) Requestor: the health care provider or designated
representative, including office staff or a referral health care provider
or health care facility that requests preauthorization, concurrent
utilization review, or voluntary certification.
(10) Work conditioning and work hardening: return-to-work
rehabilitation programs as defined in this chapter.
(b) When division-adopted treatment guidelines conflict
with this section, this section prevails.
(c) The insurance carrier is liable for all reasonable
and necessary medical costs relating to the health care:
(1) listed in subsection (p) or (q) of this section
only when the following situations occur:
(A) an emergency, as defined in Chapter 133 of this
title (relating to General Medical Provisions);
(B) preauthorization of any health care listed in subsection
(p) of this section that was approved prior to providing the health
care;
(C) concurrent utilization review of any health care
listed in subsection (q) of this section that was approved prior to
providing the health care; or
(D) when ordered by the commissioner;
(2) or per subsection (r) of this section when voluntary
certification was requested and payment agreed upon prior to providing
the health care for any health care not listed in subsection (p) of
this section.
(d) The insurance carrier is not liable under subsection
(c)(1)(B) or (C) of this section if there has been a final adjudication
that the injury is not compensable or that the health care was provided
for a condition unrelated to the compensable injury.
(e) The insurance carrier shall designate accessible
direct telephone and facsimile numbers and may designate an electronic
transmission address for use by the requestor or injured employee
to request preauthorization or concurrent utilization review during
normal business hours. The direct number shall be answered or the
facsimile or electronic transmission address responded to within the
time limits established in subsection (i) of this section. The insurance
carrier shall also comply with any additional requirements of §19.2012
of this title (relating to URA's Telephone Access and Procedures for
Certain Drug Requests and Post-Stabilization Care).
(f) The requestor or injured employee shall request
and obtain preauthorization from the insurance carrier prior to providing
or receiving health care listed in subsection (p) of this section.
Concurrent utilization review shall be requested prior to the conclusion
of the specific number of treatments or period of time preauthorized
and approval must be obtained prior to extending the health care listed
in subsection (q) of this section. The request for preauthorization
or concurrent utilization review shall be sent to the insurance carrier
by telephone, facsimile, or electronic transmission and, include the:
(1) name of the injured employee;
(2) specific health care listed in subsection (p) or
(q) of this section;
(3) number of specific health care treatments and the
specific period of time requested to complete the treatments;
(4) information to substantiate the medical necessity
of the health care requested;
(5) accessible telephone and facsimile numbers and
may designate an electronic transmission address for use by the insurance
carrier;
(6) name of the requestor and requestor's professional
license number or national provider identifier, or injured employee's
name if the injured employee is requesting preauthorization;
(7) name, professional license number or national provider
identifier of the health care provider who will render the health
care if different than paragraph (6) of this subsection and if known;
(8) facility name, and the facility's national provider
identifier if the proposed health care is to be rendered in a facility;
and
(9) estimated date of proposed health care.
(g) A health care provider may submit a request for
health care to treat an injury or diagnosis that is not accepted by
the insurance carrier in accordance with Labor Code §408.0042.
(1) The request shall be in the form of a treatment
plan for a 60 day timeframe.
(2) The insurance carrier shall review requests submitted
in accordance with this subsection for both medical necessity and
relatedness.
(3) If denying the request, the insurance carrier shall
indicate whether it is issuing an adverse determination, and/or whether
the denial is based on an unrelated injury or diagnosis in accordance
with subsection (m) of this section.
(4) The requestor or injured employee may file an extent
of injury dispute upon receipt of an insurance carrier's response
which includes a denial due to an unrelated injury or diagnosis, regardless
of whether an adverse determination was also issued.
(5) Requests which include a denial due to an unrelated
injury or diagnosis may not proceed to medical dispute resolution
based on the denial of unrelatedness. However, requests which include
the dispute of an adverse determination may proceed to medical dispute
resolution for the issue of medical necessity in accordance with subsection
(o) of this section.
(h) Except for requests submitted in accordance with
subsection (g) of this section, the insurance carrier shall either
approve or issue an adverse determination on each request based solely
on the medical necessity of the health care required to treat the
injury, regardless of:
(1) unresolved issues of compensability, extent of
or relatedness to the compensable injury;
(2) the insurance carrier's liability for the injury;
or
(3) the fact that the injured employee has reached
maximum medical improvement.
(i) The insurance carrier shall contact the requestor
or injured employee within the following timeframes by telephone,
facsimile, or electronic transmission with the decision to approve
the request; issue an adverse determination on a request; or deny
a request under subsection (g) of this section because of an unrelated
injury or diagnoses as follows:
(1) three working days of receipt of a request for
preauthorization; or
Cont'd... |