Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 12 - INDEPENDENT REVIEW ORGANIZATIONS › Subchapter C - GENERAL STANDARDS OF INDEPENDENT REVIEW › Section 12.205 - Independent Review Organization Contact with and Receipt of Information from Health Care Providers and Patients

Current through Reg. 49, No. 28; July 12, 2024
(a) A
				  health care provider may designate one or more individuals as the initial
				  contact or contacts for IROs seeking routine information or data. In no event
				  will the designation of an individual or individuals as the initial contact
				  prevent an IRO or medical director from also contacting a health care provider
				  or others in his or her employ where a review might otherwise be unreasonably
				  delayed, or where the designated individual is unable to provide the necessary
				  information or data requested by the IRO.
(b) An IRO may not engage in unnecessary or
				  unreasonably repetitive contacts with the health care provider or patient and
				  must base the frequency of contacts or reviews on the severity or complexity of
				  the patient's condition or on necessary treatment and discharge planning
				  activity.
(c) In addition to
				  pertinent files containing medical and personal information, the utilization
				  review agent or the health insurance carrier, health maintenance organization,
				  managed care entity, or other payor requesting the independent review is
				  responsible for timely delivering to and ensuring receipt by the IRO of any
				  written narrative supplied by the patient in compliance with Insurance Code
				  Chapter 4201 and Chapters 19 and 133 of this title. However, in instances of a
				  life-threatening condition, the IRO must contact the patient or patient's
				  representative, and provider directly.
(d) An IRO must notify the department if,
				  within three working days of receipt of the independent review assignment, the
				  IRO has not received the pertinent files containing medical and personal
				  information from the requesting utilization review agent or the health
				  insurance carrier, health maintenance organization, managed care entity, or
				  other payor.
(e) An IRO must
				  reimburse health care providers for the reasonable costs of providing medical
				  information in writing, including copying and transmitting any patient records
				  or other documents requested by the IRO. A health care provider's charge for
				  providing medical information to an IRO must not exceed the cost of copying set
				  by TDI-DWC rules at §
										134.120
				  of this title for records, and may not include any costs that are otherwise
				  recouped as a part of the charge for health care. The utilization review agent,
				  health insurance carrier, health maintenance organization, managed care entity,
				  or other payor requesting the review must pay these unreimbursed costs to the
				  health care provider.
(f) Nothing
				  in this section prohibits a patient, the patient's representative, or a
				  provider of record from submitting pertinent records to an IRO conducting
				  independent review.
(g) When
				  conducting independent review, the IRO must request and maintain any
				  information necessary to review the adverse determination not already provided
				  by the utilization review agent, health insurance carrier, health maintenance
				  organization, managed care entity, or other payor. This information may include
				  identifying information about the patient, the benefit plan, the treating
				  health care provider, or facilities rendering care. It may also include
				  clinical information regarding the diagnoses of the patient and the medical
				  history of the patient relevant to the diagnoses, the patient's prognosis, or
				  the treatment plan prescribed by the treating health care provider along with
				  the provider's justification for the treatment plan.
(h) The IRO is required to share all clinical
				  and demographic information on individual patients among its various divisions
				  to avoid duplication of requests for information from patients or
				  providers.