28 Tex. Admin. Code § 10.101 - General Standards for Utilization Review
(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.
Notes
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