Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 19 - LICENSING AND REGULATION OF INSURANCE PROFESSIONALS › Subchapter R - UTILIZATION REVIEWS FOR HEALTH CARE PROVIDED UNDER A HEALTH BENEFIT PLAN OR HEALTH INSURANCE POLICY › Division 1 - UTILIZATION REVIEWS › Section 19.1703 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
(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).