28 Tex. Admin. Code § 19.2016 - 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 § 19.2004 of this title (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 by a state licensing agency in the United States. 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) § 19.2005(a) of this title (relating to General Standards of Utilization Review);

(2) § 19.2006(a), (c), (d), and (e) of this title (relating to Requirements and Prohibitions Relating to Personnel);

(3) § 19.2010 of this title (relating to Requirements Prior to Issuing Adverse Determination); and

(4) § 19.2011(a)(4) and (5) 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 physician, doctor, or other health care provider of the appropriate specialty, and the plan must be implemented under standards developed with input from a physician, doctor, or other health care provider of the appropriate specialty. 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 a specialty URA to perform workers' compensation utilization review must be appropriately trained, qualified, and currently licensed as specified in Chapter 180 of this title (relating to Monitoring and Enforcement).

(2) Personnel conducting utilization review must hold an unrestricted license, an administrative license issued by a state licensing board in Texas, or be otherwise authorized to provide health care services in Texas.

(f) Utilization review by a specialty URA. Utilization review conducted by a specialty URA must be under the direction of a physician, doctor, or other health care provider of the same specialty and the physician, doctor, or other health care provider must be currently licensed to provide the specialty health care service in Texas. The physician, doctor, or other health care provider may be employed by or under contract to the URA.

(g) Reasonable opportunity for discussion. In any instance in which a specialty URA questions whether the health care is medically necessary or appropriate, the health care provider that ordered the services 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) A 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.

(2) A specialty URA must maintain, and submit to TDI or TDI-DWC 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. The specialty URA must allow the provider of record five working days to respond orally or in writing.

(h) Appeal. The decision in an appeal of any 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

28 Tex. Admin. Code § 19.2016

The provisions of this §19.2016 adopted to be effective February 20, 2013, 38 TexReg 892