28 Tex. Admin. Code § 19.1717 - Independent Review of Adverse Determinations
(a) Notification for life-threatening
conditions. For life-threatening conditions, notification of adverse
determination by a URA must be provided within the timeframes specified in §
19.1709(e)(3) of
this title (relating to Notice of Determinations Made in Utilization Review).
(1) At the time of notification of the
adverse determination, the URA must provide to the enrollee or individual
acting on behalf of the enrollee, and to the enrollee's provider of record, the
notice of the independent review process and a copy of the request for a review
by an IRO form. The notice must describe how to obtain independent review of
the adverse determination.
(2) The
enrollee, individual acting on behalf of the enrollee, or the enrollee's
provider of record must determine the existence of a life-threatening condition
on the basis that a prudent layperson possessing an average knowledge of
medicine and health would believe that the enrollee's disease or condition is a
life-threatening condition.
(b) Appeal of adverse determination involving
life-threatening condition. Any party who receives an adverse determination
involving a life-threatening condition or whose appeal of an adverse
determination is denied by the URA may seek review of that determination or
denial by an IRO assigned under Insurance Code Chapter 4202 and Chapter 12 of
this title (relating to Independent Review Organizations).
(c) Independent review involving
life-threatening and non life-threatening conditions. A URA, or insurance
carrier that made the adverse determination, must notify TDI within one working
day from the date the request for an independent review is received. The URA,
or insurance carrier that made the adverse determination, must submit the
completed request for a review by an IRO form to TDI through TDI's internet
website.
(1) Assignment of IRO. TDI will,
within one working day of receipt of a complete request for independent review,
randomly assign an IRO to conduct an independent review and notify the URA,
payor, IRO, the enrollee or individual acting on behalf of the enrollee,
enrollee's provider of record, and any other providers listed by the URA as
having records relevant to the review of the assignment.
(2) Payor and URA compliance. The payor and
URA must comply with the IRO's determination with respect to the medical
necessity, appropriateness, or the experimental or investigational nature of
the health care items and services for anenrollee.
(3) Costs of independent review. The URA must
pay for the independent review and may recover costs associated with the
independent review from the payor.
Notes
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