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 19.2011 - Written Procedures for Appeal of Adverse Determinations
Universal Citation: 28 TX Admin Code § 19.2011
Current through Reg. 50, No. 13; March 28, 2025
(a) Appeal of prospective or concurrent review adverse determinations. Each URA must comply with its written procedures for appeals. The written procedures for appeals must comply with Insurance Code Chapter 4201, Subchapter H, concerning Appeal of Adverse Determination, and must include the following provisions:
(1)
For workers' compensation network coverage, a URA must include in its written
procedures a statement specifying the timeframes for requesting the appeal
under Insurance Code §
1305.354, which may
not be less than 30 calendar days after the date of issuance of written
notification of an adverse determination.
(2) For workers' compensation non-network
coverage and workers' compensation health plans, a URA must include in its
written procedures a statement specifying that the timeframes for requesting
the appeal of the adverse determination must be consistent with §
134.600 of this title (relating to
Preauthorization, Concurrent Review, and Voluntary Certification of Health
Care) and Chapter 133, Subchapter D, of this title (relating to Dispute of
Medical Bills).
(3) An injured
employee, the injured employee's representative, or the provider of record may
appeal the adverse determination orally or in writing.
(4) Appeal decisions must be made by a
physician, dentist, or chiropractor who has not previously reviewed the case,
as required by Chapter 180 of this title (relating to Monitoring and
Enforcement); Insurance Code §
1305.354; and §
10.103 of this title (relating to
Reconsideration of Adverse Determination). If the health care services in
question are dental services, then a dentist may make the appeal decision if
the services in question are within the scope of the dentist's license to
practice dentistry. If the health care services in question are chiropractic
services, then a chiropractor may make the appeal decision if the services in
question are within the scope of the chiropractor's license to practice
chiropractic.
(5) Subject to the
notice requirements of §
19.2009 of this title (relating to
Notice of Determinations Made in Utilization Review), in any instance in which
the URA is questioning the medical necessity or appropriateness of the health
care services, prior to issuance of an adverse determination, the URA must
afford the provider of record a reasonable opportunity to discuss the plan of
treatment for the injured employee with a physician. If the health care
services in question are dental services, then a dentist may conduct the
discussion if the services in question are within the scope of the dentist's
license to practice dentistry. If the health care services in question are
chiropractic services, then a chiropractor may conduct the discussion if the
services in question are within the scope of the chiropractor's license to
practice chiropractic. The provision must state that the discussion must
include, at a minimum, the clinical basis for the URA's decision.
(6) After the URA has sought review of the
appeal of the adverse determination, the URA must issue a response letter
explaining the resolution of the appeal to individuals specified in §
19.2009(a) of
this title (relating to Notice of Determinations Made in Utilization
Review).
(7) The response letter
required in paragraph (6) of this subsection, for both workers' compensation
network coverage and for workers' compensation non-network coverage, must
include:
(A) a statement of the specific
medical or dental reasons for the resolution;
(B) the clinical basis for the
decision;
(C) the professional
specialty and Texas license number of the physician, dentist, or chiropractor
who made the determination;
(D)
notice of the appealing party's right to seek review of the adverse
determination by an IRO under §
19.2017 of this title (relating to
Independent Review of Adverse Determinations), the notice of the independent
review process, and 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 or health care provider;
(E) procedures for filing a complaint as
described in §
19.2005(f) of
this title (relating to General Standards of Utilization Review);
(F) for workers' compensation network
coverage only, a description or the source of the screening criteria that were
utilized in making the determination, including a description of the network
adopted treatment guidelines, if any; and
(G) for workers' compensation non-network
coverage only, a description of treatment guidelines utilized under Chapter 137
of this title (relating to Disability Management) or Labor Code §
504.054(b)
in making a determination;
(8) Timeframes required for written
notifications to the appealing party of the determination of the appeal:
(A) must be resolved as specified in §
10.103 of this title for workers'
compensation network coverage; and
(B) must be resolved as specified in §
134.600 of this title for workers'
compensation non-network coverage.
(9) In a circumstance involving an injured
employee's life-threatening condition, or involving a request for a medical
interlocutory order under §
134.550 of this title (Medical
Interlocutory Order), the injured employee is entitled to an immediate review
by an IRO of the adverse determination and is not required to comply with
procedures for an appeal of the adverse determination by the URA.
(b) Appeal of retrospective review adverse determinations. A URA must maintain and make available a written description of appeal procedures involving an adverse determination in a retrospective review. The appeal procedures must comply with § 19.2009 of this title for retrospective utilization review adverse determination appeals and Insurance Code § 4201.359. The written procedures for appeals must specify that an injured employee, the injured employee's representative, or the provider of record may appeal the adverse determination orally or in writing.
(1)
Workers' compensation network coverage. For workers' compensation network
coverage, appeal procedures must comply with the requirements in Insurance Code
Chapter 1305, §
10.102 of this title (relating to
Notice of Certain Utilization Review Determinations; Preauthorization and
Retrospective Review Requirements), and §
133.250 of this title (relating to
Reconsideration for Payment of Medical Bills).
(2) Workers' compensation non-network
coverage. For workers' compensation non-network coverage, the appeal procedures
must comply with the requirements of §
133.250 of this title.
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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