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 19.1709 - Notice of Determinations Made in Utilization Review

Current through Reg. 49, No. 28; July 12, 2024
(a) Notice requirements. A URA must send
					 written notification to the enrollee or an individual acting on behalf of the
					 enrollee and the enrollee's provider of record, including the health care
					 provider who rendered the service, of a determination made in a utilization
					 review.
(b) Renewal of existing
					 preauthorizations. If a health benefit plan issuer subject to Insurance Code
					 Chapter 1222 requires preauthorization as a condition of payment for a medical
					 or health care service, the URA must provide a preauthorization renewal process
					 that allows a physician or health care provider to request renewal of an
					 existing preauthorization at least 60 days before the date the preauthorization
					 expires.
(c) Required notice
					 elements. In all instances of a prospective, concurrent, or retrospective
					 utilization review adverse determination, written notification of the adverse
					 determination by the URA must include:
(1) the
					 principal reasons for the adverse determination;
(2) the clinical basis for the adverse
					 determination;
(3) a description or
					 the source of the screening criteria that were utilized as guidelines in making
					 the determination;
(4) the
					 professional specialty of the physician, doctor, or other health care provider
					 that made the adverse determination;
(5) a description of the procedure for the
					 URA's complaint system as required by §
												19.1705
					 of this title (relating to General Standards of Utilization Review);
(6) a description of the URA's appeal
					 process, as required by §
												19.1711
					 of this title (relating to Written Procedures for Appeal of Adverse
					 Determination);
(7) a copy of the
					 request for a review by an IRO form, available at www.tdi.texas.gov;
(8) notice of the independent review process
					 with instructions that:
(A) request for a
					 review by an IRO form must be completed by the enrollee, an individual acting
					 on behalf of the enrollee, or the enrollee's provider of record and be returned
					 to the insurance carrier or URA that made the adverse determination to begin
					 the independent review process; and
(B) the release of medical information to the
					 IRO, which is included as part of the independent review request for a review
					 by an IRO form, must be signed by the enrollee or the enrollee's legal
					 guardian; and
(9) a
					 description of the enrollee's right to an immediate review by an IRO and of the
					 procedures to obtain that review for an enrollee who has a life-threatening
					 condition or who is denied the provision of prescription drugs or intravenous
					 infusions for which the patient is receiving benefits under the health
					 insurance policy.