28 Tex. Admin. Code § 12.202 - Personnel and Credentialing

(a) Personnel employed by or under contract with the IRO to perform independent reviews must be appropriately trained, qualified, and, if applicable, currently licensed, registered, or certified. These personnel must be currently involved in an active practice. An exception to the active practice requirement is the medical director of the IRO. Personnel who obtain information directly from a physician, dentist, or other health care provider, either orally or in writing, and who are not physicians or dentists, must be nurses, physician assistants, or health care providers qualified to provide the service requested by the provider. This provision must not be interpreted to require such qualifications for personnel who perform clerical or administrative tasks.

(1) Personnel conducting independent reviews for health services must hold an unrestricted license, an administrative license, or otherwise be authorized to provide the same or similar specialty health services by a licensing agency in the United States.

(2) Personnel conducting independent reviews for workers' compensation health care services must hold an unrestricted license, an administrative license, or otherwise be authorized to provide the same or similar specialty workers' compensation health care services by a licensing agency in this state.

(b) The IRO is required to provide to the commissioner:

(1) the name, type, license number, state of licensure, date of contract, and minimum qualifications of the personnel either employed or under contract to perform the independent review; and

(2) written procedures used to determine whether physicians or other health care providers used by the IRO are licensed, qualified, in good standing, and appropriately trained.

(c) An IRO must be under the direction of a medical director who is a physician currently licensed and in good standing to practice medicine by a state licensing agency in the United States. The medical director functions must include, but are not limited to, conducting:

(1) annual review and approval of review criteria;

(2) annual quality assurance audits of at least 25 percent of all decisions to ensure appropriate reviews are conducted, and to provide quality assurance reports to the department when requested; and

(3) annual quality assurance audits of at least 25 percent of all assignments to ensure appropriate reviewers are assigned to cases, and to provide quality assurance reports to the department when requested.

(d) The IRO must maintain credentialing and recredentialing files of personnel who are either employed or under contract to perform independent reviews. At a minimum, the IRO must keep the following credentialing and recredentialing information current and available for review by the department and TDI-DWC on request:

(1) verification obtained from the applicable state licensing board that licensure, certification, or registration is in effect at the time of the credentialing decision;

(2) active practice in effect at the time of the credentialing decision;

(3) board certification, if applicable. The IRO may obtain verification from the American Board of Medical Specialties Compendium, the American Osteopathic Association, the American Medical Association MasterFile, or an applicable specialty board. The certification must be in effect at the time of the credentialing decision; and

(4) any sanctions or revocations by any state licensing agencies in the United States or the U.S. Department of Health and Human Services (HHS) in effect at the time of the credentialing decision. The IRO must verify sanctions or revocations with state licensing agencies, TDI-DWC, and the HHS Office of Inspector General.

(e) Notwithstanding subsections (c) and (d) of this section, a physician, dentist, or other person who performs independent review whose license has been revoked by any state licensing agency in the United States is not eligible to direct or conduct independent review.

(f) Notwithstanding subsection (c) of this section, an IRO that performs independent review of a health care service provided under Labor Code Title 5 or Insurance Code Chapter 1305 must comply with the licensing and professional specialty requirements for personnel performing independent review as provided by Labor Code §§ 408.0043 - 408.0045 and 413.031; Insurance Code § 1305.355; and Chapters 133 and 180 of this title.

(g) The IRO must require physicians and other providers who conduct independent reviews to sign and date the certification of independence and qualifications of the reviewer in the format prescribed by the department. The certification of independence and qualifications of the reviewer includes certification that the physician or other provider who conducts the independent review:

(1) holds an unrestricted license, certification, or registration and lists the relevant states, license numbers, and expiration dates;

(2) has no sanctions or revocations of the reviewer's license, certification, or registration by any state licensing agency in the United States or HHS;

(3) currently practices and lists the states;

(4) has no previous knowledge of or participation in the case before it is assigned to the reviewer;

(5) has no disqualifying associations, including business or personal relationships, with any involved parties in the case;

(6) does not have admitting privileges or ownership interest in, and is not a member of the board of directors, advisor to the board of directors, or officer of the health care facilities where care was provided or is recommended to be provided;

(7) does not have a contract with or an ownership interest in the utilization review agent, insurer, health maintenance organization, other managed care entity, payor, or any other party to the case and is not a member of the board or advisor to the board of directors or an officer for any of the above referenced entities; and

(8) performed the review without bias for or against the utilization review agent, the insurer, health maintenance organization, other managed care entity, payor, or any other party to this case.

(h) The information required in this section must be available for examination and review by the department and TDI-DWC personnel on request.

(i) The IRO must require those physicians and other providers who conduct independent reviews to notify the IRO of any changes in the information in subsection (d) of this section.

Notes

28 Tex. Admin. Code § 12.202

The provisions of this §12.202 adopted to be effective November 26, 1997, 22 TexReg 11363; amended to be effective December 26, 2010, 35 TexReg 11281; Amended by Texas Register, Volume 40, Number 19, May 8, 2015, TexReg 2565, eff. 7/7/2015