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 19.2009 - Notice of Determinations Made in Utilization Review
Universal Citation: 28 TX Admin Code § 19.2009
Current through Reg. 50, No. 13; March 28, 2025
(a) Notice requirements of favorable or adverse determinations.
(1) A URA must send
written notification of a determination made in utilization review to the
individuals specified in and within the timeframes required for utilization
review.
(2) For prospective and
concurrent review, the timeframes are specified by:
(A) Section
134.600 of this title (relating to
Preauthorization, Concurrent Review, and Voluntary Certification of Health
Care) for workers' compensation non-network coverage; and
(B) Insurance Code §
1305.353, concerning
Notice of Certain Utilization Review Determinations; Preauthorization
Requirements; and §
10.102 of this title (relating to
Notice of Certain Utilization Review Determinations; Preauthorization and
Retrospective Review Requirements) for workers' compensation network
coverage.
(3) For
retrospective review, the timeframes are specified by:
(A) Sections
133.240 and
133.250 of this title (relating to
Medical Payment and Denials, and Reconsideration for Payment of Medical Bills,
respectively) for workers' compensation non-network coverage;
(B) Sections
133.240,
133.250, and
10.102 of this title, for workers'
compensation network coverage.
(4) For workers' compensation non-network
coverage and network coverage, a URA must ensure that preauthorization numbers
assigned by the URA comply with the data and format requirements contained in
the standards adopted by the U.S. Department of Health and Human Services in 45
Code of Federal Regulations §162.1102 (relating to Standards for Health
Care Claims or Equivalent Encounter Information Transaction) based on the type
of service in the preauthorization request.
(b) Required notice elements. In all instances of a prospective, concurrent, or retrospective utilization review adverse determination, written notification of the adverse determination by the URA must include:
(1) the principal reasons
for the adverse determination;
(2)
the clinical basis for the adverse determination;
(3) a description of the procedure for filing
a complaint with TDI;
(4) the
professional specialty and Texas license number of the physician, doctor, or
other health care provider that made the adverse determination;
(5) a description of the procedure for the
URA's complaint system as required by §
19.2005 of this title (relating to
General Standards of Utilization Review);
(6) a description of the URA's appeal
process, as required by §
19.2011 of this title (relating to
Written Procedures for Appeal of Adverse Determination) and a statement that in
a circumstance involving an injured employee's life-threatening condition, the
injured employee is entitled to an immediate review of the adverse
determination by an IRO and is not required to comply with procedures for an
internal review of the adverse determination by the URA for prospective and
concurrent utilization review;
(7)
for workers' compensation network coverage, a description or the source of the
screening criteria used in making the determination, including a description of
treatment guidelines used, as applicable;
(8) for workers' compensation non-network
coverage, a description of treatment guidelines used under Chapter 137 of this
title (relating to Disability Management) or Labor Code §
504.054(b)
in making a determination; and
(9)
notice of the independent review process. The notice of the independent review
process required under this paragraph must include:
(A) a statement that:
(i) the request for a review by an IRO form
must be completed by the injured employee, the injured employee's
representative, or the injured employee's provider of record and be returned to
the insurance carrier or URA that made the adverse determination to begin the
independent review process;
(ii) a
request for independent review of an adverse determination made under workers'
compensation non-network coverage must be timely filed by the requestor
consistent with §
133.308 of this title (relating to
MDR of Medical Necessity Disputes); and
(iii) a request for independent review of an
adverse determination made under workers' compensation network coverage must be
timely filed by the requestor consistent with §
10.104 of this title (relating to
Independent Review of Adverse Determination); and
(B) either of the following:
(i) a copy of the request for a review by an
IRO form, available at www.tdi.texas.gov/forms; or
(ii) notice in at least 12 point font that
the injured employee can obtain a copy of the request for a review by an IRO
form by:
(I) accessing TDI's website at
www.tdi.texas.gov/forms; or
(II)
calling {insert URA's telephone number} to request a copy of the form, at which
time the URA will send a copy of the request for a review by an IRO form to the
injured employee.
(c) Peer review reports. The notice of determination made in utilization review required under this section and the peer review report required by § 180.28 of this title (relating to Peer Review Requirements, Reporting, and Sanctions) may be combined into one document if all the requirements of both sections are met.
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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