28 Tex. Admin. Code § 10.104 - Independent Review of Adverse Determination
(a) Requirements for independent review of an
adverse determination are governed by Insurance Code Chapter 1305, concerning
Workers' Compensation Health Care Networks, and department and Division of
Workers' Compensation rules, including Chapter 10, Subchapter F, of this title
(relating to Utilization Review), Chapter 12 of this title (relating to
Independent Review Organizations), Chapter 19 of this title (relating to
Licensing and Regulation of Insurance Professionals), and §
133.308 of this title (relating to
MDR of Medical Necessity Disputes).
(b) The person who performs utilization
review; denies a referral request because the referral is not medically
necessary; or denies a request for deviation from treatment guidelines,
individual treatment protocols, or screening criteria must:
(1) permit the employee, person acting on
behalf of the employee, or the employee's requesting provider to seek review of
the referral denial or reconsideration denial within the period prescribed by
subsection (c) of this section by an independent review organization assigned
in accordance with Insurance Code Chapter 4202, concerning Independent Review
Organizations, and department and Division of Workers' Compensation rules;
and
(2) provide to the appropriate
independent review organization the information and documents listed in §
133.308(k) of
this title (relating to MDR of Medical Necessity Disputes) and the response
letter described by Insurance Code §
1305.354(a)(4),
concerning Reconsideration of Adverse Determination, not later than the third
business day after the date the person receives notification of the assignment
of the request to an independent review organization.
(c) A requestor must timely file a request
for independent review under subsection (b) of this section as follows:
(1) for a request regarding preauthorization
or concurrent review, not later than the 45th day after the date of denial of a
reconsideration; or
(2) for a
request regarding retrospective medical necessity review, not later than the
45th day after the denial of reconsideration.
(d) The insurance carrier must pay for the
independent review provided under this subchapter.
(e) The department will assign the review
request to an independent review organization.
(f) A decision of an independent review
organization related to a request for preauthorization or concurrent review is
binding during any review under this section. The carrier is liable for health
care during the pendency of any appeal, and the carrier and network must comply
with the decision.
(g) A party to a
medical dispute that remains unresolved after a review under this section is
entitled to a contested case hearing. A hearing under this section will be
conducted by the Division of Workers' Compensation in the same manner as a
hearing conducted under Labor Code §
413.0311, concerning
Review of Medical Necessity Disputes; Contested Case Hearing, and Division of
Workers' Compensation rules.
(h)
The department and the Division of Workers' Compensation are not considered to
be parties to the medical dispute.
(i) If review is not sought under subsection
(g) of this section, the carrier and network must comply with the independent
review organization's decision.
Notes
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