Texas Administrative Code
Title 28 - INSURANCE
Part 1 - TEXAS DEPARTMENT OF INSURANCE
Chapter 10 - WORKERS' COMPENSATION HEALTH CARE NETWORKS
Subchapter F - UTILIZATION REVIEW
Section 10.104 - Independent Review of Adverse Determination

Universal Citation: 28 TX Admin Code § 10.104

Current through Reg. 50, No. 13; March 28, 2025

(a) Requirements for independent review of an adverse determination are governed by Insurance Code Chapter 1305, concerning Workers' Compensation Health Care Networks, and department and Division of Workers' Compensation rules, including Chapter 10, Subchapter F, of this title (relating to Utilization Review), Chapter 12 of this title (relating to Independent Review Organizations), Chapter 19 of this title (relating to Licensing and Regulation of Insurance Professionals), and § 133.308 of this title (relating to MDR of Medical Necessity Disputes).

(b) The person who performs utilization review; denies a referral request because the referral is not medically necessary; or denies a request for deviation from treatment guidelines, individual treatment protocols, or screening criteria must:

(1) permit the employee, person acting on behalf of the employee, or the employee's requesting provider to seek review of the referral denial or reconsideration denial within the period prescribed by subsection (c) of this section by an independent review organization assigned in accordance with Insurance Code Chapter 4202, concerning Independent Review Organizations, and department and Division of Workers' Compensation rules; and

(2) provide to the appropriate independent review organization the information and documents listed in § 133.308(k) of this title (relating to MDR of Medical Necessity Disputes) and the response letter described by Insurance Code § 1305.354(a)(4), concerning Reconsideration of Adverse Determination, not later than the third business day after the date the person receives notification of the assignment of the request to an independent review organization.

(1) for a request regarding preauthorization or concurrent review, not later than the 45th day after the date of denial of a reconsideration; or

(2) for a request regarding retrospective medical necessity review, not later than the 45th day after the denial of reconsideration.

(d) The insurance carrier must pay for the independent review provided under this subchapter.

(e) The department will assign the review request to an independent review organization.

(f) A decision of an independent review organization related to a request for preauthorization or concurrent review is binding during any review under this section. The carrier is liable for health care during the pendency of any appeal, and the carrier and network must comply with the decision.

(g) A party to a medical dispute that remains unresolved after a review under this section is entitled to a contested case hearing. A hearing under this section will be conducted by the Division of Workers' Compensation in the same manner as a hearing conducted under Labor Code § 413.0311, concerning Review of Medical Necessity Disputes; Contested Case Hearing, and Division of Workers' Compensation rules.

(h) The department and the Division of Workers' Compensation are not considered to be parties to the medical dispute.

(i) If review is not sought under subsection (g) of this section, the carrier and network must comply with the independent review organization's decision.

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