Current through Reg. 50, No. 13; March 28, 2025
(a)
Personnel employed by or under contract with the IRO to perform independent
reviews must be appropriately trained, qualified, and, if applicable, currently
licensed, registered, or certified. These personnel must be currently involved
in an active practice. An exception to the active practice requirement is the
medical director of the IRO. Personnel who obtain information directly from a
physician, dentist, or other health care provider, either orally or in writing,
and who are not physicians or dentists, must be nurses, physician assistants,
or health care providers qualified to provide the service requested by the
provider. This provision must not be interpreted to require such qualifications
for personnel who perform clerical or administrative tasks.
(1) Personnel conducting independent reviews
for health services must hold an unrestricted license, an administrative
license, or otherwise be authorized to provide the same or similar specialty
health services by a licensing agency in the United States.
(2) Personnel conducting independent reviews
for workers' compensation health care services must hold an unrestricted
license, an administrative license, or otherwise be authorized to provide the
same or similar specialty workers' compensation health care services by a
licensing agency in this state.
(b) The IRO is required to provide to the
commissioner:
(1) the name, type, license
number, state of licensure, date of contract, and minimum qualifications of the
personnel either employed or under contract to perform the independent review;
and
(2) written procedures used to
determine whether physicians or other health care providers used by the IRO are
licensed, qualified, in good standing, and appropriately trained.
(c) An IRO must be under the
direction of a medical director who is a physician currently licensed and in
good standing to practice medicine by a state licensing agency in the United
States. The medical director functions must include, but are not limited to,
conducting:
(1) annual review and approval of
review criteria;
(2) annual quality
assurance audits of at least 25 percent of all decisions to ensure appropriate
reviews are conducted, and to provide quality assurance reports to the
department when requested; and
(3)
annual quality assurance audits of at least 25 percent of all assignments to
ensure appropriate reviewers are assigned to cases, and to provide quality
assurance reports to the department when requested.
(d) The IRO must maintain credentialing and
recredentialing files of personnel who are either employed or under contract to
perform independent reviews. At a minimum, the IRO must keep the following
credentialing and recredentialing information current and available for review
by the department and TDI-DWC on request:
(1)
verification obtained from the applicable state licensing board that licensure,
certification, or registration is in effect at the time of the credentialing
decision;
(2) active practice in
effect at the time of the credentialing decision;
(3) board certification, if applicable. The
IRO may obtain verification from the American Board of Medical Specialties
Compendium, the American Osteopathic Association, the American Medical
Association MasterFile, or an applicable specialty board. The certification
must be in effect at the time of the credentialing decision; and
(4) any sanctions or revocations by any state
licensing agencies in the United States or the U.S. Department of Health and
Human Services (HHS) in effect at the time of the credentialing decision. The
IRO must verify sanctions or revocations with state licensing agencies,
TDI-DWC, and the HHS Office of Inspector General.
(e) Notwithstanding subsections (c) and (d)
of this section, a physician, dentist, or other person who performs independent
review whose license has been revoked by any state licensing agency in the
United States is not eligible to direct or conduct independent
review.
(f) Notwithstanding
subsection (c) of this section, an IRO that performs independent review of a
health care service provided under Labor Code Title 5 or Insurance Code Chapter
1305 must comply with the licensing and professional specialty requirements for
personnel performing independent review as provided by Labor Code §§
408.0043 -
408.0045 and
413.031; Insurance Code
§
1305.355; and Chapters
133 and 180 of this title.
(g) The
IRO must require physicians and other providers who conduct independent reviews
to sign and date the certification of independence and qualifications of the
reviewer in the format prescribed by the department. The certification of
independence and qualifications of the reviewer includes certification that the
physician or other provider who conducts the independent review:
(1) holds an unrestricted license,
certification, or registration and lists the relevant states, license numbers,
and expiration dates;
(2) has no
sanctions or revocations of the reviewer's license, certification, or
registration by any state licensing agency in the United States or
HHS;
(3) currently practices and
lists the states;
(4) has no
previous knowledge of or participation in the case before it is assigned to the
reviewer;
(5) has no disqualifying
associations, including business or personal relationships, with any involved
parties in the case;
(6) does not
have admitting privileges or ownership interest in, and is not a member of the
board of directors, advisor to the board of directors, or officer of the health
care facilities where care was provided or is recommended to be
provided;
(7) does not have a
contract with or an ownership interest in the utilization review agent,
insurer, health maintenance organization, other managed care entity, payor, or
any other party to the case and is not a member of the board or advisor to the
board of directors or an officer for any of the above referenced entities;
and
(8) performed the review
without bias for or against the utilization review agent, the insurer, health
maintenance organization, other managed care entity, payor, or any other party
to this case.
(h) The
information required in this section must be available for examination and
review by the department and TDI-DWC personnel on request.
(i) The IRO must require those physicians and
other providers who conduct independent reviews to notify the IRO of any
changes in the information in subsection (d) of this section.
