Current through Reg. 50, No. 13; March 28, 2025
(a) An IRO must notify the patient or
patient's representative, the patient's provider of record, the utilization
review agent, the payor, and the department of a determination made in an
independent review.
(b) For a
situation other than a situation described in subsection (c) of this section,
the notification required by this section must be mailed or otherwise
transmitted no later than the earlier of:
(1)
The 15th day after the date the IRO receives the information necessary to make
a determination; or
(2) the 20th
day after the date the IRO receives the request for the independent
review.
(c) In the case
of a life-threatening condition, the provision of prescription drugs or
intravenous infusions for which the patient is receiving benefits under a
health insurance policy, or a review of a step therapy protocol exception
request under Insurance Code §
1369.0546, the
notification must be by telephone, and followed by facsimile, email, or other
method of transmission no later than the earlier of:
(1) the third day after the date the IRO
receives the information necessary to make a determination; or with respect
to:
(2) a review of a health care
service provided to a person eligible for workers' compensation medical
benefits, the eighth day after the date the IRO receives the request that the
determination be made; or
(3) a
review of health care service other than a service described by paragraph (2)
of this subsection, the third day after the date the IRO receives the request
that the determination be made.
(d) Notification of determination by the IRO
is required to include at a minimum:
(1) a
listing of all recipients of the notification of determination as described in
subsection (a) of this section, identifying for each:
(B) as applicable to the manner of
transmission used to issue the notification of determination to the recipient:
(ii) facsimile number; or
(2) the date of the original
notice of the decision, and if amended for any reason, the date of the amended
notification of decision;
(3) the
independent review case number assigned by the department;
(4) the name of the patient;
(5) a statement about whether the type of
coverage is health insurance, workers' compensation, or workers' compensation
health care network;
(6) a
statement about whether the context of the review is preauthorization,
concurrent utilization review, or retrospective utilization review of health
care services;
(7) the name and
certificate of registration number of the IRO;
(8) a description of the services in
dispute;
(9) a complete list of the
information provided to the IRO for review, including dates of service and
document dates, where applicable;
(10) a description of the qualifications of
the reviewing physician or provider;
(11) a statement that the review was
performed without bias for or against any party to the dispute and that the
reviewing physician or provider has certified that no known conflicts of
interest exist between the reviewer and:
(B) the patient's
employer, if applicable;
(D) the utilization review
agent;
(E) any of the treating
physicians or providers; or
(F) any
of the physicians or providers who reviewed the case for determination before
its referral to the IRO, and that the review was performed without bias for or
against any party to the dispute;
(12) a statement that the independent review
was performed by a health care provider licensed to practice in Texas, if
required by applicable law and of the appropriate professional
specialty;
(13) a statement that
there is no known conflict of interest between the reviewer, the IRO, and any
officer or employee of the IRO with:
(B) the provider
requesting independent review;
(C)
the provider of record;
(D) the
utilization review agent;
(F) the certified
workers' compensation health care network, if applicable;
(14) a summary of the patient's clinical
history;
(15) the review outcome,
clearly stating whether medical necessity or appropriateness exists for each of
the health care services in dispute and whether the health care services in
dispute are experimental or investigational, as applicable;
(16) a determination of the prevailing party,
if applicable;
(17) the analysis
and explanation of the decision, including the clinical bases, findings, and
conclusions used to support the decision;
(18) a description and the source of the
review criteria used to make the determination;
(19) a certification by the IRO of the date
the decision was sent to all recipients of the notification of determination as
required in subsection (a) of this section by U.S. Postal Service or otherwise
transmitted in the manner indicated on the form;
(20) for independent reviews of health care
services provided under Labor Code Title 5 or Insurance Code Chapter 1305, any
information required by §
133.308 of this title;
and
(21) notice of applicable
appeal rights under Insurance Code Chapter 1305 and Labor Code Title 5, and
instructions concerning requesting such appeal.
(e) Example templates for the notification of
determination regarding health and workers' compensation cases are on the
department's website at tdi.texas.gov/forms.
