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 19.2011 - 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 the following provisions:
(1)
				  For workers' compensation network coverage, a URA must include in its written
				  procedures a statement specifying the timeframes for requesting the appeal
				  under Insurance Code §
											1305.354,
				  which may not be less than 30 calendar days after the date of issuance of
				  written notification of an adverse determination.
(2) For workers' compensation non-network
				  coverage and workers' compensation health plans, a URA must include in its
				  written procedures a statement specifying that the timeframes for requesting
				  the appeal of the adverse determination must be consistent with §
											134.600
				  of this title (relating to Preauthorization, Concurrent Review, and Voluntary
				  Certification of Health Care) and Chapter 133, Subchapter D, of this title
				  (relating to Dispute of Medical Bills).
(3) An injured employee, the injured
				  employee's representative, or the provider of record may appeal the adverse
				  determination orally or in writing.
(4) Appeal decisions must be made by a
				  physician, dentist, or chiropractor who has not previously reviewed the case,
				  as required by Chapter 180 of this title (relating to Monitoring and
				  Enforcement); Insurance Code §
											1305.354;
				  and §
											10.103
				  of this title (relating to Reconsideration of Adverse Determination). If the
				  health care services in question are dental services, then a dentist may make
				  the appeal decision if the services in question are within the scope of the
				  dentist's license to practice dentistry. If the health care services in
				  question are chiropractic services, then a chiropractor may make the appeal
				  decision if the services in question are within the scope of the chiropractor's
				  license to practice chiropractic.
(5) Subject to the notice requirements of
				  §
											19.2009
				  of this title (relating to Notice of Determinations Made in Utilization
				  Review), in any instance in which the URA is questioning the medical necessity
				  or appropriateness of the health care services, prior to issuance of an adverse
				  determination, the URA must afford the provider of record a reasonable
				  opportunity to discuss the plan of treatment for the injured employee with a
				  physician. If the health care services in question are dental services, then a
				  dentist may conduct the discussion if the services in question are within the
				  scope of the dentist's license to practice dentistry. If the health care
				  services in question are chiropractic services, then a chiropractor may conduct
				  the discussion if the services in question are within the scope of the
				  chiropractor's license to practice chiropractic. The provision must state that
				  the discussion must include, at a minimum, the clinical basis for the URA's
				  decision.
(6) After the URA has
				  sought review of the appeal of the adverse determination, the URA must issue a
				  response letter explaining the resolution of the appeal to individuals
				  specified in §
											19.2009(a)
				  of this title (relating to Notice of Determinations Made in Utilization
				  Review).
(7) The response letter
				  required in paragraph (6) of this subsection, for both workers' compensation
				  network coverage and for workers' compensation non-network coverage, must
				  include:
(A) a statement of the specific
				  medical or dental reasons for the resolution;
(B) the clinical basis for the
				  decision;
(C) the professional
				  specialty and Texas license number of the physician, dentist, or chiropractor
				  who made the determination;
(D)
				  notice of the appealing party's right to seek review of the adverse
				  determination by an IRO under §
												19.2017
				  of this title (relating to Independent Review of Adverse Determinations), the
				  notice of the independent review process, and either of the following:
(i) a copy of the request for a review by an
				  IRO form, available at www.tdi.texas.gov/forms; or
(ii) notice in at least 12 point font that
				  the injured employee can obtain a copy of the request for a review by an IRO
				  form by:
(I) accessing TDI's website, at
				  www.tdi.texas.gov/forms; or
(II)
				  calling {insert URA's telephone number} to request a copy of the form, at which
				  time the URA will send a copy of the request for a review by an IRO form to the
				  injured employee or health care provider;
(E) procedures for filing a complaint as
				  described in §
												19.2005(f)
				  of this title (relating to General Standards of Utilization Review);
(F) for workers' compensation network
				  coverage only, a description or the source of the screening criteria that were
				  utilized in making the determination, including a description of the network
				  adopted treatment guidelines, if any; and
(G) for workers' compensation non-network
				  coverage only, a description of treatment guidelines utilized under Chapter 137
				  of this title (relating to Disability Management) or Labor Code §
												504.054(b)
				  in making a determination;
(8) Timeframes required for written
				  notifications to the appealing party of the determination of the appeal:
(A) must be resolved as specified in §
												10.103
				  of this title for workers' compensation network coverage; and
(B) must be resolved as specified in §
												134.600
				  of this title for workers' compensation non-network coverage.
(9) In a circumstance involving an
				  injured employee's life-threatening condition, or involving a request for a
				  medical interlocutory order under §
											134.550
				  of this title (Medical Interlocutory Order), the injured employee is entitled
				  to an immediate review by an IRO of the adverse determination and is not
				  required to comply with procedures for an appeal of the adverse determination
				  by the URA.