Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 19 - LICENSING AND REGULATION OF INSURANCE PROFESSIONALS › Subchapter U - UTILIZATION REVIEWS FOR HEALTH CARE PROVIDED UNDER WORKERS' COMPENSATION INSURANCE COVERAGE › Section 19.2005 - General Standards of Utilization Review

Current through Reg. 49, No. 28; July 12, 2024
(a) Review of utilization review plan. A
				  utilization review plan must be reviewed and approved by a physician and
				  conducted under standards developed and periodically updated with input from
				  both primary and specialty physicians, doctors, and other health care
				  providers, including practicing health care providers, as
				  appropriate.
(b) Special
				  circumstances. A utilization review determination must be made in a manner that
				  takes special circumstances of the case into account that may require deviation
				  from the norm stated in the screening criteria or relevant guidelines. Special
				  circumstances include, but are not limited to, an individual who has a
				  disability, acute condition, or life-threatening illness. For the purposes of
				  this section, disability must not be construed to mean an injured employee who
				  is off work or receiving income benefits.
(c) Screening criteria. Each URA must utilize
				  written screening criteria that are evidence-based, scientifically valid,
				  outcome-focused, and that comply with the requirements in Insurance Code §
										4201.153.
				  The screening criteria must also recognize that if evidence-based medicine is
				  not available for a particular health care service provided, the URA must
				  utilize generally accepted standards of medical practice recognized in the
				  medical community. For workers' compensation network coverage, screening
				  criteria must comply with Insurance Code Chapter 1305 and §
										10.101
				  of this title (relating to General Standards for Utilization Review and
				  Retrospective Review); for workers' compensation non-network coverage and
				  workers' compensation health plan, screening criteria must comply with Labor
				  Code §§
										401.011,
				  413.011,
				  and
				  413.014,
				  and Chapters 133, 134, and 137 of this title (relating to General Medical
				  Provisions; Benefits-Guidelines for Medical Services, Charges, and Payments;
				  and Disability Management, respectively).
(d) Referral and determination of adverse
				  determinations. Adverse determinations must be referred to and may only be
				  determined by a physician, doctor, or other health care provider with
				  appropriate credentials under Chapter 180 of this title (relating to Monitoring
				  and Enforcement) and §
										19.2006
				  of this title (relating to Requirements and Prohibitions Relating to
				  Personnel). Physicians and doctors performing utilization review must also
				  comply with Labor Code §§
										408.0043,
				  408.0044,
				  and
				  408.0045.
(e) Delegation of review. A URA, including a
				  specialty URA, may delegate the utilization review to qualified personnel in a
				  hospital or other health care facility in which the health care services to be
				  reviewed were, or are, to be provided. The delegation does not relieve the URA
				  of full responsibility for compliance with this subchapter, Insurance Code
				  Chapter 4201, the Texas Workers' Compensation Act, and applicable TDI-DWC
				  rules, including responsibility for the conduct of those to whom utilization
				  review has been delegated.
(f)
				  Complaint system. The URA must develop and implement procedures for the
				  resolution of oral or written complaints initiated by injured employees, their
				  representatives, or health care providers concerning the utilization review.
				  The URA must maintain records of complaints for three years from the date the
				  complaints are filed. The complaints procedure must include a requirement for a
				  written response to the complainant by the agent within 30 calendar days. The
				  written response must include TDI's address, toll-free telephone number, and a
				  statement explaining that a complainant is entitled to file a complaint with
				  TDI.
(g) Compliance with Labor Code
				  §
										504.055.
				  Utilization review plan written policies must evidence compliance with Labor
				  Code §
										504.055,
				  concerning Expedited Provision of Medical Benefits for Certain Injuries
				  Sustained by First Responder in Course and Scope of Employment.