Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 134 - BENEFITS-GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS › Subchapter G - PROSPECTIVE AND CONCURRENT REVIEW OF HEALTH CARE › Section 134.600 - Preauthorization, Concurrent Utilization Review, and Voluntary Certification of Health Care

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