28 Tex. Admin. Code § 12.205 - Independent Review Organization Contact with and Receipt of Information from Health Care Providers and Patients
(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.
Notes
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