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 19.2003 - 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 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. For the purposes of this subchapter, an adverse
				  determination does not include a determination that health care services are
				  experimental or investigational.
(2) Appeal--The URA's formal process by which
				  an injured employee, an injured employee's representative, or an injured
				  employee's provider of record may request reconsideration of an adverse
				  determination. For the purposes of this subchapter the term also applies to
				  reconsideration processes prescribed by Labor Code Title 5 and applicable rules
				  for workers' compensation.
(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 that is registered as a URA under §
											19.2004
				  of this title (relating to Certification or Registration of URAs).
(5) Commissioner--As defined in Insurance
				  Code §
											31.001.
(6) Compensable injury--As defined in Labor
				  Code §
											401.011.
(7) 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.
(8)
				  Concurrent utilization review--A form of utilization review for ongoing health
				  care or for an extension of treatment beyond previously approved health
				  care.
(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, or 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 Labor Code or
				  applicable TDI-DWC rules, Insurance Code or applicable TDI rules, or any other
				  association with the injured employee, employer, or insurance carrier that may
				  give the appearance of preventing the reviewing physician, doctor, or other
				  health care provider from rendering an unbiased opinion.
(10) Doctor--As defined in Labor Code §
											401.011.
(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--As defined in Labor Code §
											401.011.
(13) Health care facility--As defined in
				  Labor Code §
											401.011.
(14) Insurance carrier or insurer--As defined
				  in Labor Code §
											401.011.
(15) Independent review organization or
				  IRO--As defined in §
											12.5 of
				  this title (relating to Definitions).
(16) 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.
(17) Medical benefit--As defined in Labor
				  Code §
											401.011.
(18) Medical emergency--The sudden onset of a
				  medical condition manifested by acute symptoms of sufficient severity,
				  including severe pain that the absence of immediate medical attention could
				  reasonably be expected to result in:
(A)
				  placing the injured employee's health or bodily functions in serious jeopardy;
				  or
(B) serious dysfunction of any
				  body organ or part.
(19)
				  Medical records--The history of diagnosis of and treatment for an injury,
				  including medical, mental health records as allowed by law, dental, and other
				  health care records from all disciplines providing care to an injured
				  employee.
(20) Mental health
				  medical record summary--A summary of process or progress notes relevant to
				  understanding the injured employee'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 injured
				  employee behaviors or thought processes that affect level of care needs;
				  and
(iv) discharge plan.
(21) 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,
				  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.
(22) Mental or
				  emotional condition or disorder--A mental or emotional illness as detailed in
				  the most current Diagnostic and Statistical Manual of Mental
				  Disorders.
(23) Payor--Any person
				  or entity that provides, offers to provide, or administers hospital,
				  outpatient, medical, or other health benefits, including workers' compensation
				  benefits, to an individual treated by a health care provider under a policy,
				  plan, statute, or contract.
(24)
				  Peer review--An administrative review by a health care provider performed at
				  the insurance carrier's request without a physical examination of the injured
				  employee.
(25) 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, a political subdivision of this state, the statewide
				  rural health care system under Insurance Code Chapter 845, and any similar
				  entity.
(26) Preauthorization--A
				  form of prospective utilization review by a payor or a payor's URA of health
				  care services proposed to be provided to an injured employee.
(27) 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 an injured employee, or
				  a physician, doctor, or other health care provider that has rendered or has
				  been requested to provide health care services to an injured employee. This
				  definition includes any health care facility where health care services are
				  rendered on an inpatient or outpatient basis.
(28) 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.
(29) Registration--The process for an
				  insurance carrier to register with TDI to perform utilization review solely for
				  injured employees covered by workers' compensation insurance coverage issued by
				  the insurance carrier.
(30) 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, or insurance carrier that made the adverse determination.
(31) Retrospective utilization review--A form
				  of utilization review for health care services that have been provided to an
				  injured employee. 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.
(32) Screening criteria--The written
				  policies, decision rules, medical protocols, or treatment guidelines used by a
				  URA as part of the utilization review process.
(33) TDI--The Texas Department of
				  Insurance.
(34) TDI-DWC--The Texas
				  Department of Insurance, Division of Workers' Compensation.
(35) Texas Workers' Compensation Act--Labor
				  Code Title 5, Subtitle A.
(36)
				  Treating doctor--As defined in Labor Code §
											401.011.
(37) URA--Utilization review agent.
(38) URA application--Form for application
				  for, renewal of, and reporting a material change to a certification or
				  registration as a URA in this state.
(39) Workers' compensation health care
				  network--As defined in Insurance Code §
											1305.004.
(40) Workers' compensation health
				  plan--Health care provided by a political subdivision contracting directly with
				  health care providers or through a health benefits pool, under Labor Code
				  §
											504.053(b)(2).
(41) Workers' compensation insurance
				  coverage--As defined in Labor Code §
											401.011.
(42) Workers' compensation network
				  coverage--Health care provided under a workers' compensation health care
				  network.
(43) Workers' compensation
				  non-network coverage--Health care delivered under Labor Code Title 5, excluding
				  health care provided under Insurance Code Chapter 1305.