Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 10 - WORKERS' COMPENSATION HEALTH CARE NETWORKS › Subchapter F - UTILIZATION REVIEW › Section 10.101 - General Standards for Utilization Review

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  Screening criteria used for utilization review related to a workers'
				  compensation health care network must be consistent with the network's
				  treatment guidelines, return-to-work guidelines, and individual treatment
				  protocols.
(b) The carrier's
				  utilization review program must include a process for a treating doctor or
				  specialist to request approval from the network for deviation from the
				  treatment guidelines, return-to-work guidelines, and individual treatment
				  protocols where required by the particular circumstances of an employee's
				  injury.
(c) Under Insurance Code
				  §
										4201.152,
				  concerning Utilization Review Under Physician, a network that uses doctors to
				  perform reviews of health care services provided under this chapter, including
				  utilization review, or peer reviews under Labor Code §
										408.0231(a),
				  concerning Maintenance of List of Approved Doctors; Sanctions and Privileges
				  Relating to Health Care, may only use doctors licensed to practice in this
				  state.
(d) Physicians and doctors
				  conducting utilization review must hold a professional certification in a
				  health care specialty appropriate to the type of health care the injured
				  employee is receiving as required by Labor Code §§
										408.0043
				  -
				  408.0045,
				  concerning Professional Specialty Certification Required for Certain Review,
				  Review of Dental Services, and Review of Chiropractic Services. Physicians,
				  doctors, and other health care providers conducting utilization review must
				  have the appropriate credentials as required by Chapter 180 of this title
				  (relating to Monitoring and Enforcement).
(e) The preauthorization requirements of
				  Labor Code §
										413.014,
				  concerning Preauthorization Requirements; Concurrent Review and Certification
				  of Health Care, and rules adopted under that section do not apply to health
				  care provided through a workers' compensation network. If a carrier or network
				  uses a preauthorization process within a network, the requirements of Insurance
				  Code Chapter 1305, Subchapter H, concerning Utilization Review, and this
				  chapter apply.
(f) Insurance Code
				  Chapter 1305, Subchapter H, and applicable network requirements in Chapter 19,
				  Subchapter U, of this title (relating to Utilization Reviews for Health Care
				  Provided Under Workers' Compensation Insurance Coverage), apply to utilization
				  review for health care provided through a workers' compensation network that is
				  conducted by insurance carriers, utilization review agents, and networks that
				  perform utilization review for or on behalf of insurance carriers and
				  utilization review agents.
(g) In
				  addition to the requirements in subsection (f) of this section, the
				  reconsideration procedures must include a method for expedited reconsideration
				  procedures in accordance with Insurance Code §
										1305.354(b)
				  and (c), concerning Reconsideration of
				  Adverse Determination.