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 19.1711 - Written Procedures for Appeal of Adverse Determinations

Current through Reg. 49, No. 28; July 12, 2024
(a) Appeal of prospective or concurrent
					 review adverse determinations. Each URA must comply with its written procedures
					 for appeals. The written procedures for appeals must comply with Insurance Code
					 Chapter 4201, Subchapter H, concerning Appeal of Adverse Determination, and
					 must include provisions that specify the following:
(1) Time frames for filing the written or
					 oral appeal, which may not be less than 30 calendar days after the date of
					 issuance of written notification of an adverse determination.
(2) An enrollee, an individual acting on
					 behalf of the enrollee, or the provider of record may appeal the adverse
					 determination orally or in writing.
(3) An appeal acknowledgement letter must:
(A) be sent to the appealing party within
					 five working days from receipt of the appeal;
(B) acknowledge the date the URA received the
					 appeal;
(C) include a list of
					 relevant documents that must be submitted by the appealing party to the URA;
					 and
(D) include a one-page appeal
					 form to be filled out by the appealing party when the URA receives an oral
					 appeal of an adverse determination.
(4) Appeal decisions must be made by a
					 physician who has not previously reviewed the case.
(5) In any instance in which the URA is
					 questioning the medical necessity, the appropriateness, or the experimental or
					 investigational nature, of the health care services prior to issuance of
					 adverse determination, the URA must afford the provider of record a reasonable
					 opportunity to discuss the plan of treatment for the enrollee with a physician.
					 The provision must require that the discussion include, at a minimum, the
					 clinical basis for the URA's decision.
(6) If an appeal is requested or denied and,
					 within 10 working days from the request or denial, the health care provider
					 requests a particular type of specialty provider review the case, the appeal or
					 the decision denying the appeal must be reviewed by a health care provider in
					 the same or similar specialty that typically manages the medical, dental, or
					 specialty condition, procedure, or treatment under discussion for review of the
					 adverse determination. The specialty review must be completed within 15 working
					 days of receipt of the request. The provision must state that notification of
					 the appeal under this paragraph must be in writing.
(7) In addition to the written appeal, a
					 method for expedited appeals is available for denials of emergency care,
					 continued stays for hospitalized enrollees, or prescription drugs or
					 intravenous infusions for which an enrollee is receiving benefits under the
					 health insurance policy; adverse determinations of a step therapy protocol
					 exception request under Insurance Code §
												1369.0546;
					 or a denial of another service if the requesting health care provider includes
					 a written statement with supporting documentation that the service is necessary
					 to treat a life-threatening condition or prevent serious harm to the patient.
					 The provision must state that:
(A) the
					 procedure must include a review by a health care provider who has not
					 previously reviewed the case and who is of the same or a similar specialty as
					 the health care provider that typically manages the medical condition,
					 procedure, or treatment under review;
(B) an expedited appeal must be completed
					 based on the immediacy of the medical or dental condition, procedure, or
					 treatment, but may in no event exceed one working day from the date all
					 information necessary to complete the appeal is received; and
(C) an expedited appeal determination may be
					 provided by telephone or electronic transmission but must be followed with a
					 letter within three working days of the initial telephonic or electronic
					 notification.
(8) After
					 the URA has sought review of the appeal of the adverse determination, the URA
					 must issue a response letter to the enrollee or an individual acting on behalf
					 of the enrollee, and the provider of record, explaining the resolution of the
					 appeal. If there is an adverse determination of the appeal, the letter must
					 include:
(A) a statement of the specific
					 medical, dental, or contractual reasons for the resolution;
(B) the clinical basis for the
					 decision;
(C) a description of or
					 the source of the screening criteria that were utilized in making the
					 determination;
(D) the professional
					 specialty of the physician who made the determination;
(E) notice of the appealing party's right to
					 seek review of the adverse determination by an IRO under §
													19.1717
					 of this title (relating to Independent Review of Adverse
					 Determinations);
(F) notice of the
					 independent review process;
(G) a
					 copy of a request for a review by an IRO form; and
(H) procedures for filing a complaint as
					 described in §
													19.1705(f)
					 of this title (relating to General Standards of Utilization
					 Review).
(9) A statement
					 that the appeal must be resolved as soon as practical, but, under Insurance
					 Code §
												4201.359 and
					 §
												1352.006,
					 in no case later than 30 calendar days after the date the URA receives the
					 appeal from the appealing party referenced under paragraph (3) of this
					 subsection.
(10) In a circumstance
					 involving an enrollee's life-threatening condition or the denial of
					 prescription drugs or intravenous infusions for which the enrollee is receiving
					 benefits under the health insurance policy, the enrollee is entitled to an
					 immediate appeal to an IRO and is not required to comply with procedures for an
					 appeal of the URA's adverse determination.