28 Tex. Admin. Code § 19.1716 - Specialty URA
(a) Application. To be
certified or registered as a specialty URA, an applicant must submit to TDI the
application, information, and fee required in §
19.1704 of this title (relating to
Certification or Registration of URAs).
(b) Same specialty required. A specialty URA
must conduct utilization review under the direction of a health care provider
who is of the same specialty as the agent and who is licensed or otherwise
authorized to provide the specialty health care service in Texas. To conduct
utilization review, a specialty URA must be of the same specialty as the health
care provider who ordered the service. For example, when conducting utilization
review of prescription drugs prescribed by a physician with a specialty in
neurological surgery, the specialty URA must be a physician with a specialty in
neurological surgery.
(c) Rule
requirements. A specialty URA is subject to the requirements of this
subchapter, except for the following provisions:
(1) Section
19.1705(a) of
this title (relating to General Standards of Utilization Review);
(2) Section
19.1706(a), (c), and
(d) of this title (relating to Requirements
and Prohibitions Relating to Personnel);
(3) Section
19.1710 of this title (relating to
Requirements Prior to Issuing Adverse Determination); and
(4) Section
19.1711(a)(4) -
(6) of this title (relating to Written
Procedures for Appeal of Adverse Determination).
(d) Utilization review plan. A specialty URA
must have its utilization review plan, including appeal requirements, reviewed
by a health care provider of the appropriate specialty who is licensed or
otherwise authorized to provide the specialty health care service in Texas, and
the plan must be implemented under standards developed with input from a health
care provider of the appropriate specialty who is licensed or otherwise
authorized to provide the specialty health care service in Texas. The specialty
URA must have written procedures to ensure that these requirements are
implemented.
(e) Requirements of
employed or contracted physicians, doctors, other health care providers, and
personnel.
(1) Physicians, doctors, other
health care providers, and personnel employed by or under contract with the
specialty URA to perform utilization review must be appropriately trained,
qualified, and currently licensed.
(2) Personnel conducting specialty
utilization review must hold an unrestricted license, an administrative license
issued by a state licensing board, or be otherwise authorized to provide health
care services by a licensing agency in the United States.
(f) Reasonable opportunity for discussion. In
any instance in which a specialty URA questions the medical necessity, the
appropriateness, or the experimental or investigational nature of the health
care services, the health care provider of record must, prior to the issuance
of an adverse determination, be afforded a reasonable opportunity to discuss
the plan of treatment for the patient and the clinical basis for the decision
of the URA with a health care provider of the same specialty as the URA. The
discussion must include, at a minimum, the clinical basis for the specialty
URA's decision and a description of documentation or evidence, if any, that can
be submitted by the provider of record that, on appeal, might lead to a
different utilization review decision.
(1)
The specialty URA's telephone number must be provided to the provider of record
so that the provider of record may contact the specialty URA to discuss the
pending adverse determination. For a retrospective utilization review, the
specialty URA must allow the provider of record five working days to respond
orally or in writing.
(2) The
specialty URA must maintain, and submit to TDI on request, documentation that
details the discussion opportunity provided to the provider of record,
including the date and time the specialty URA offered the opportunity to
discuss the adverse determination; the date and time that the discussion, if
any, took place; and the discussion outcome.
(g) Appeal. The decision in any appeal of an
adverse determination by a specialty URA must be made by a physician or other
health care provider who has not previously reviewed the case and who is of the
same specialty as the specialty URA that made the adverse
determination.
Notes
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