[(2)Network Appeal Procedures. A party to a medical necessity dispute may seek judicial review of a dismissal or the decision as provided in Insurance Code §1305.355 and Chapter 10 of this title (relating to Workers' Compensation Healthcare Networks).] [(u)Non-Network Spinal Surgery Appeal. A party to a preauthorization or concurrent medical necessity dispute regarding spinal surgery may appeal the IRO decision in accordance with Labor Code §413.031(l) by requesting a Contested Case Hearing (CCH).] [(1)The written appeal must be filed with the Division Chief Clerk no later than 20 days after the date the IRO decision is sent to the appealing party and must be filed in compliance with Division rules.] [(2)The CCH must be scheduled and held not later than 20 days after Division receipt of the request for a CCH.] [(3)The hearing and further appeals shall be conducted in accordance with Chapters 140, 142, and 143 of this title (relating to Dispute Resolution/General Provisions, Benefit Contested Case Hearing, and Review by the Appeals Panel).] [(4)The party appealing the IRO decision shall deliver a copy of its written request for a hearing to all other parties involved in the dispute. The IRO is not required to participate in the CCH or any appeal.] (t)[(v)] Medical Fee Dispute Request. If the requestor has an unresolved non-network fee dispute related to health care that was found medically necessary, after the final decision of the medical necessity dispute, the requestor may file a medical fee dispute in accordance with §133.305 and §133.307 of this title [subchapter] (relating to MDR-General and MDR of Fee Disputes, respectively). (u)In accordance with Labor Code §504.055(d), a first responder's request for an appeal regarding the denial of a claim for medical benefits, including all health care required to cure or relieve the effects naturally resulting from a compensable injury will be accelerated by the division and given priority. The first responder shall provide notice to the division and independent review organization that the contested case hearing or appeal involves a first responder. (v) [(w)] Enforcement. The department or the division may initiate appropriate proceedings under Chapter 12 of this title (relating to Independent Review Organizations) or Labor Code, Title 5 and division rules against an independent review organization or a person conducting independent reviews. [If the Department believes that any person is in violation of the Labor Code, Insurance Code, or related rules, the Department may initiate an enforcement action. Nothing in this section modifies or limits the authority of the Department or the Division.]
This agency hereby certifies that the proposal has
been reviewed by legal counsel and found to be within the agency's
legal authority to adopt.
Filed with the Office
of the Secretary of State on
March 12, 2012
TRD-201201373 Dirk Johnson
General Counsel
Texas Department of Insurance, Division of Workers' Compensation
Earliest possible date of adoption: April 22, 2012
For further information, please call: (512) 804-4703
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