28 Tex. Admin. Code § 134.600 - Preauthorization, Concurrent Utilization Review, and Voluntary Certification of Health Care
(a) The following words
and terms when used in this chapter shall have the following meanings, unless
the context clearly indicates otherwise:
(1)
Adverse determination: A determination by a utilization review agent made on
behalf of a payor that the health care services provided or proposed to be
provided to an injured employee are not medically necessary or appropriate. The
term does not include a denial of health care services due to the failure to
request prospective or concurrent utilization review. An adverse determination
does not include a determination that health care services are experimental or
investigational.
(2) Ambulatory
surgical services: surgical services provided in a facility that operates
primarily to provide surgical services to patients who do not require overnight
hospital care.
(3) Concurrent
utilization review: a form of utilization review for on-going health care
listed in subsection (q) of this section for an extension of treatment beyond
previously approved health care listed in subsection (p) of this
section.
(4) Diagnostic study: any
test used to help establish or exclude the presence of disease/injury in
symptomatic individuals. The test may help determine the diagnosis, screen for
specific disease/injury, guide the management of an established disease/injury,
and formulate a prognosis.
(5)
Final adjudication: the commissioner has issued a final decision or order that
is no longer subject to appeal by either party.
(6) Outpatient surgical services: surgical
services provided in a freestanding surgical center or a hospital outpatient
department to patients who do not require overnight hospital care.
(7) Preauthorization: a form of prospective
utilization review by a payor or a payor's utilization review agent of health
care services proposed to be provided to an injured employee.
(8) Reasonable opportunity: At least one
documented good faith attempt to contact the provider of record that provides
an opportunity for the provider of record to discuss the services under review
with the utilization review agent during normal business hours prior to issuing
a prospective, concurrent, or retrospective utilization review adverse
determination:
(A) no less than one working
day prior to issuing a prospective utilization review adverse
determination;
(B) no less than
five working days prior to issuing a retrospective utilization review adverse
determination; or
(C) prior to
issuing a concurrent or post-stabilization review adverse
determination.
(9)
Requestor: the health care provider or designated representative, including
office staff or a referral health care provider or health care facility that
requests preauthorization, concurrent utilization review, or voluntary
certification.
(10) Work
conditioning and work hardening: return-to-work rehabilitation programs as
defined in this chapter.
(b) When division-adopted treatment
guidelines conflict with this section, this section prevails.
(c) The insurance carrier is liable for all
reasonable and necessary medical costs relating to the health care:
(1) listed in subsection (p) or (q) of this
section only when the following situations occur:
(A) an emergency, as defined in Chapter 133
of this title (relating to General Medical Provisions);
(B) preauthorization of any health care
listed in subsection (p) of this section that was approved prior to providing
the health care;
(C) concurrent
utilization review of any health care listed in subsection (q) of this section
that was approved prior to providing the health care; or
(D) when ordered by the
commissioner;
(2) or per
subsection (r) of this section when voluntary certification was requested and
payment agreed upon prior to providing the health care for any health care not
listed in subsection (p) of this section.
(d) The insurance carrier is not liable under
subsection (c)(1)(B) or (C) of this section if there has been a final
adjudication that the injury is not compensable or that the health care was
provided for a condition unrelated to the compensable injury.
(e) The insurance carrier shall designate
accessible direct telephone and facsimile numbers and may designate an
electronic transmission address for use by the requestor or injured employee to
request preauthorization or concurrent utilization review during normal
business hours. The direct number shall be answered or the facsimile or
electronic transmission address responded to within the time limits established
in subsection (i) of this section. The insurance carrier shall also comply with
any additional requirements of §
19.2012 of this title (relating to
URA's Telephone Access and Procedures for Certain Drug Requests and
Post-Stabilization Care).
(f) The
requestor or injured employee shall request and obtain preauthorization from
the insurance carrier prior to providing or receiving health care listed in
subsection (p) of this section. Concurrent utilization review shall be
requested prior to the conclusion of the specific number of treatments or
period of time preauthorized and approval must be obtained prior to extending
the health care listed in subsection (q) of this section. The request for
preauthorization or concurrent utilization review shall be sent to the
insurance carrier by telephone, facsimile, or electronic transmission and,
include the:
(1) name of the injured
employee;
(2) specific health care
listed in subsection (p) or (q) of this section;
(3) number of specific health care treatments
and the specific period of time requested to complete the treatments;
(4) information to substantiate the medical
necessity of the health care requested;
(5) accessible telephone and facsimile
numbers and may designate an electronic transmission address for use by the
insurance carrier;
(6) name of the
requestor and requestor's professional license number or national provider
identifier, or injured employee's name if the injured employee is requesting
preauthorization;
(7) name,
professional license number or national provider identifier of the health care
provider who will render the health care if different than paragraph (6) of
this subsection and if known;
(8)
facility name, and the facility's national provider identifier if the proposed
health care is to be rendered in a facility; and
(9) estimated date of proposed health
care.
(g) A health care
provider may submit a request for health care to treat an injury or diagnosis
that is not accepted by the insurance carrier in accordance with Labor Code §
408.0042.
(1) The request shall be in the form of a
treatment plan for a 60 day timeframe.
(2) The insurance carrier shall review
requests submitted in accordance with this subsection for both medical
necessity and relatedness.
(3) If
denying the request, the insurance carrier shall indicate whether it is issuing
an adverse determination, and/or whether the denial is based on an unrelated
injury or diagnosis in accordance with subsection (m) of this
section.
(4) The requestor or
injured employee may file an extent of injury dispute upon receipt of an
insurance carrier's response which includes a denial due to an unrelated injury
or diagnosis, regardless of whether an adverse determination was also
issued.
(5) Requests which include
a denial due to an unrelated injury or diagnosis may not proceed to medical
dispute resolution based on the denial of unrelatedness. However, requests
which include the dispute of an adverse determination may proceed to medical
dispute resolution for the issue of medical necessity in accordance with
subsection (o) of this section.
(h) Except for requests submitted in
accordance with subsection (g) of this section, the insurance carrier shall
either approve or issue an adverse determination on each request based solely
on the medical necessity of the health care required to treat the injury,
regardless of:
(1) unresolved issues of
compensability, extent of or relatedness to the compensable injury;
(2) the insurance carrier's liability for the
injury; or
(3) the fact that the
injured employee has reached maximum medical improvement.
(i) The insurance carrier shall contact the
requestor or injured employee within the following timeframes by telephone,
facsimile, or electronic transmission with the decision to approve the request;
issue an adverse determination on a request; or deny a request under subsection
(g) of this section because of an unrelated injury or diagnoses as follows:
(1) three working days of receipt of a
request for preauthorization; or
(2) three working days of receipt of a
request for concurrent utilization review, except for health care listed in
subsection (q)(1) of this section, which is due within one working day of the
receipt of the request.
(j) The insurance carrier shall send written
notification of the approval of the request, adverse determination on the
request, or denial of the request under subsection (g) of this section because
of an unrelated injury or diagnosis within one working day of the decision to
the:
(1) injured employee;
(2) injured employee's representative;
and
(3) requestor, if not
previously sent by facsimile or electronic transmission.
(k) The insurance carrier's failure to comply
with any timeframe requirements of this section shall result in an
administrative violation.
(l) The
insurance carrier shall not withdraw a preauthorization or concurrent
utilization review approval once issued. The approval shall include:
(1) the specific health care;
(2) the approved number of health care
treatments and specific period of time to complete the treatments;
(3) a notice of any unresolved dispute
regarding the denial of compensability or liability or an unresolved dispute of
extent of or relatedness to the compensable injury; and
(4) the insurance carrier's preauthorization
approval number that conforms to the standards described in §
19.2009(a)(4) of
this title (relating to Notice of Determinations Made in Utilization
Review).
(m) In
accordance with §
19.2010 of this title (relating to
Requirements Prior to Issuing Adverse Determination), the insurance carrier
shall afford the requestor a reasonable opportunity to discuss the clinical
basis for the adverse determination prior to issuing the adverse determination.
The notice of adverse determination must comply with the requirements of §
19.2009 of this title and if
preauthorization is denied under Labor Code §
408.0042 because the
treatment is for an injury or diagnosis unrelated to the compensable injury the
notice must include notification to the injured employee and health care
provider of entitlement to file an extent of injury dispute in accordance with
Chapter 141 of this title (relating to Dispute Resolution--Benefit Review
Conference).
(n) The insurance
carrier shall not condition an approval or change any elements of the request
as listed in subsection (f) of this section, unless the condition or change is
mutually agreed to by the health care provider and insurance carrier and is
documented.
(o) If the initial
response is an adverse determination of preauthorization or concurrent
utilization review, the requestor or injured employee may request
reconsideration orally or in writing. A request for reconsideration under this
section constitutes an appeal for the purposes of §
19.2011 of this title (relating to
Written Procedures for Appeal of Adverse Determinations).
(1) The requestor or injured employee may
within 30 days of receipt of a written adverse determination request the
insurance carrier to reconsider the adverse determination and shall document
the reconsideration request.
(2)
The insurance carrier shall respond to the request for reconsideration of the
adverse determination:
(A) as soon as
practicable but not later than the 30th day after receiving a request for
reconsideration of an adverse determination of preauthorization; or
(B) within three working days of receipt of a
request for reconsideration of an adverse determination of concurrent
utilization review, except for health care listed in subsection (q)(1) of this
section, which is due within one working day of the receipt of the
request.
(3) In addition
to the requirements in this section and §
19.2011 of this title, the
insurance carrier's reconsideration procedures shall include a provision that
the period during which the reconsideration is to be completed shall be based
on the medical or clinical immediacy of the condition, procedure, or
treatment.
(4) In any instance
where the insurance carrier is questioning the medical necessity or
appropriateness of the health care services prior to the issuance of an adverse
determination on the request for reconsideration, the insurance carrier shall
comply with the requirements of §
19.2010 and §
19.2011 of this title, including
the requirement that the insurance carrier afford the requestor a reasonable
opportunity to discuss the proposed health care with a doctor or, in cases of a
dental plan or chiropractic services, with a dentist or chiropractor,
respectively.
(5) The requestor or
injured employee may appeal the denial of a reconsideration request regarding
an adverse determination by filing a dispute in accordance with Labor Code §
413.031 and related
division rules.
(6) A request for
preauthorization for the same health care shall only be resubmitted when the
requestor provides objective clinical documentation to support a substantial
change in the injured employee's medical condition or that demonstrates that
the injured employee has met clinical prerequisites for the requested health
care that had not been previously met before submission of the previous
request. The insurance carrier shall review the documentation and determine if
any substantial change in the injured employee's medical condition has occurred
or if all necessary clinical prerequisites have been met. A frivolous
resubmission of a preauthorization request for the same health care constitutes
an administrative violation.
(p) Non-emergency health care requiring
preauthorization includes:
(1) inpatient
hospital admissions, including the principal scheduled procedure(s) and the
length of stay;
(2) outpatient
surgical or ambulatory surgical services as defined in subsection (a) of this
section;
(3) spinal
surgery;
(4) all work hardening or
work conditioning services;
(5)
physical and occupational therapy services, which includes those services
listed in the Healthcare Common Procedure Coding System (HCPCS) at the
following levels:
(A) Level I code range for
Physical Medicine and Rehabilitation, but limited to:
(i) Modalities, both supervised and constant
attendance;
(ii) Therapeutic
procedures, excluding work hardening and work conditioning;
(iii) Orthotics/Prosthetics
Management;
(iv) Other procedures,
limited to the unlisted physical medicine and rehabilitation procedure code;
and
(B) Level II
temporary code(s) for physical and occupational therapy services provided in a
home setting;
(C) except for the
first six visits of physical or occupational therapy following the evaluation
when such treatment is rendered within the first two weeks immediately
following:
(i) the date of injury;
or
(ii) a surgical intervention
previously preauthorized by the insurance carrier;
(6) any investigational or
experimental service or device for which there is early, developing scientific
or clinical evidence demonstrating the potential efficacy of the treatment,
service, or device but that is not yet broadly accepted as the prevailing
standard of care;
(7) all
psychological testing and psychotherapy, repeat interviews, and biofeedback,
except when any service is part of a preauthorized return-to-work
rehabilitation program;
(8) unless
otherwise specified in this subsection, a repeat individual diagnostic study:
(A) with a reimbursement rate of greater than
$350 as established in the current Medical Fee Guideline; or
(B) without a reimbursement rate established
in the current Medical Fee Guideline;
(9) all durable medical equipment (DME) in
excess of $500 billed charges per item (either purchase or expected cumulative
rental);
(10) chronic pain
management/interdisciplinary pain rehabilitation;
(11) drugs not included in the applicable
division formulary;
(12) treatments
and services that exceed or are not addressed by the commissioner's adopted
treatment guidelines or protocols and are not contained in a treatment plan
preauthorized by the insurance carrier. This requirement does not apply to
drugs prescribed for claims under §§
134.506,
134.530 or
134.540 of this title (relating to
Pharmaceutical Benefits);
(13)
required treatment plans; and
(14)
any treatment for an injury or diagnosis that is not accepted by the insurance
carrier pursuant to Labor Code §
408.0042 and §
126.14 of this title (relating to
Treating Doctor Examination to Define the Compensable
Injury).
(q) The health
care requiring concurrent utilization review for an extension for previously
approved services includes:
(1) inpatient
length of stay;
(2) all work
hardening or work conditioning services;
(3) physical and occupational therapy
services as referenced in subsection (p)(5) of this section;
(4) investigational or experimental services
or use of devices;
(5) chronic pain
management/interdisciplinary pain rehabilitation; and
(6) required treatment plans.
(r) The requestor and insurance
carrier may voluntarily discuss health care that does not require
preauthorization or concurrent utilization review under subsections (p) and (q)
of this section respectively.
(1) Denial of a
request for voluntary certification is not subject to dispute resolution for
prospective review of medical necessity.
(2) The insurance carrier may certify health
care requested. The carrier and requestor shall document the agreement. Health
care provided as a result of the agreement is not subject to retrospective
utilization review of medical necessity.
(3) If there is no agreement between the
insurance carrier and requestor, health care provided is subject to
retrospective utilization review of medical necessity.
(s) An increase or decrease in review and
preauthorization controls may be applied to individual doctors or individual
workers' compensation claims by the division in accordance with Labor Code §
408.0231(b)(4)
and other sections of this title.
(t) The insurance carrier shall maintain
accurate records to reflect information regarding requests for
preauthorization, or concurrent utilization review approval or adverse
determination decisions, and appeals, including requests for reconsideration
and requests for medical dispute resolution, if any. The insurance carrier
shall also maintain accurate records to reflect information regarding requests
for voluntary certification approval/denial decisions. Upon request of the
division, the insurance carrier shall submit such information in the form and
manner prescribed by the division.
(u) For the purposes of this section, all
utilization review must be performed by an insurance carrier that is registered
with, or a utilization review agent that is certified by, the Texas Department
of Insurance to perform utilization review in accordance with Insurance Code
Chapter 4201 and Chapter 19 of this title (relating to Licensing and Regulation
of Insurance Professionals).
(1) All
utilization review agents or registered insurance carriers who perform
utilization review under this section must comply with Labor Code §
504.055 and any other
provisions of Chapter 19, Subchapter U of this title (relating to Utilization
Reviews for Health Care Provided under Workers' Compensation Insurance
Coverage) that relate to the expedited provision of medical benefits to first
responders employed by political subdivisions who sustain a serious bodily
injury in the course and scope of employment.
(2) In accordance with Labor Code §
501.028(b),
an insurance carrier must accelerate and give priority to a claim for medical
benefits:
(A) by a member of the Texas
military forces who,
(i) while on state active
duty,
(ii) sustains a serious
bodily injury, as defined by Penal Code §
1.07;
(B) including all health care required to
cure or relieve the effects naturally resulting from a compensable
injury.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.