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(J)other information that was required by the Department related to a request from a carrier or the carrier's URA for the assignment of the IRO. (3)Network Appeal Procedures. A party to a medical necessity dispute may seek judicial review of the decision as provided in Insurance Code §1305.355. (s)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 10 days after receipt of the IRO decision and must be filed in compliance with §142.5(c) of this title (relating to Sequence of Proceedings to Resolve Benefit Disputes). (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)Medical Fee Dispute Request. If the health care provider has an unresolved fee dispute related to health care that was found medically necessary, after the final decision of the medical necessity dispute, the provider may file a medical fee dispute in accordance with §133.305 and §133.307 of this subchapter (relating to MDR of Fee Disputes). (u)Enforcement. If the Department believes that any person is in violation of the Labor Code, Insurance Code and 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 adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of
the Secretary of State on December 11, 2006
TRD-200606593 Norma Garcia
General Counsel
Texas Department of Insurance, Division of Workers' Compensation
Effective date: December 31, 2006
Proposal publication date: June 23, 2006
For further information, please call: (512) 804-4288
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