Texas Administrative Code
Title 28 - INSURANCE
Part 1 - TEXAS DEPARTMENT OF INSURANCE
Chapter 12 - INDEPENDENT REVIEW ORGANIZATIONS
Subchapter A - GENERAL PROVISIONS
Section 12.6 - Independent Review of Adverse Determinations of Health Care Provided Under Labor Code Title 5 or Insurance Code Chapter 1305

Universal Citation: 28 TX Admin Code § 12.6

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

(a) Review of the medical necessity or appropriateness of a health care service provided under Labor Code Chapter 408 or Chapter 413 must be conducted under this chapter in the same manner as reviews of utilization review decisions by health maintenance organizations.

(b) Notwithstanding subsection (a) of this section, for independent review of adverse determinations of health care provided under Labor Code Title 5 or Insurance Code Chapter 1305:

(1) IROs and personnel conducting independent review must comply with Labor Code Title 5 and applicable TDI-DWC rules;

(2) in the event of a conflict between this chapter and the Labor Code, the Labor Code controls; and

(3) in the event of a conflict between this chapter and TDI-DWC rules, TDI-DWC rules control.

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