Texas Administrative Code
Title 28 - INSURANCE
Part 1 - TEXAS DEPARTMENT OF INSURANCE
Chapter 19 - LICENSING AND REGULATION OF INSURANCE PROFESSIONALS
Subchapter U - UTILIZATION REVIEWS FOR HEALTH CARE PROVIDED UNDER WORKERS' COMPENSATION INSURANCE COVERAGE
Section 19.2007 - URA Contact with and Receipt of Information from Health Care Providers

Universal Citation: 28 TX Admin Code § 19.2007

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

(a) If a URA must reimburse health care providers for providing medical information under Insurance Code § 4201.207, reimbursement is limited to the reasonable costs for providing medical records relevant to the utilization review that were requested by the URA in writing. A health care provider's charge for providing medical information to a URA must comply with § 134.120 of this title (relating to Reimbursement for Medical Documentation) and may not include any costs that are recouped as a part of the charge for health care. Nothing in this subsection removes the health care provider's requirement to provide information to substantiate the medical necessity of health care requested under Chapter 134 of this title (relating to Benefits--Guidelines for Medical Services, Charges, and Payments) or to submit required documentation when submitting a medical bill under Chapter 133 of this title (relating to General Medical Provisions).

(b) When conducting utilization review, a URA must request all relevant and updated information and medical records to complete the review.

(1) This information may include identifying information about the injured employee; the claim; the treating physician, doctor, or other health care provider; and the facilities rendering care. It may also include clinical and diagnostic testing information regarding the diagnoses of the injured employee and the medical history of the injured employee relevant to the diagnoses and the compensable injury, the injured employee's prognosis, and the plan of treatment prescribed by the provider of record, along with the provider of record's justification for the plan of treatment. The required information should be requested from the appropriate sources.

(2) A URA must not routinely request copies of all medical records on injured employees reviewed. During utilization review, copies of the necessary or pertinent sections of medical records should only be required when a difficulty develops in determining whether the health care is medically necessary or appropriate or experimental or investigational in nature.

(c) The URA must share among its various divisions all clinical and demographic information on individual injured employees to avoid duplicate requests for information from injured employees, physicians, doctors, and other health care providers.

(d) A URA may not require as a condition of approval of a health care service, or for any other reason, the observation of a psychotherapy session or the submission or review of a mental health therapist's process or progress notes that relate to the mental health therapist's treatment of an injured employee's mental or emotional condition or disorder. This prohibition extends to requiring an oral, electronic, facsimile, or written submission or rendition of a mental health therapist's process or progress notes. This prohibition does not preclude the URA from requiring submission of:

(1) an injured employee's mental health medical record summary; or

(2) medical records or process or progress notes that relate to treatment of conditions or disorders other than a mental or emotional condition or disorder.

Disclaimer: These regulations may not be the most recent version. Texas may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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