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 19.2017 - Independent Review of Adverse Determinations
Universal Citation: 28 TX Admin Code § 19.2017
Current through Reg. 50, No. 13; March 28, 2025
(a) Life-threatening conditions.
(1) Notification for life-threatening
conditions. For life-threatening conditions, notification of an adverse
determination by a URA must comply with:
(A)
Section 134.600 of this title (relating to
Preauthorization, Concurrent Review, and Voluntary Certification of Health
Care) for workers' compensation non-network coverage;
(B) Insurance Code §
1305.353 and §
10.102 of this title (relating to
Notice of Certain Utilization Review Determinations; Preauthorization and
Retrospective Review Requirements) for workers' compensation network coverage;
and
(C) Section
19.2009(a)(2) of
this title (relating to Notice of Determinations Made in Utilization Review),
including notice of the independent review process and the procedure for
obtaining a copy of the request for a review by an IRO form. The notice must
describe how to obtain independent review of the adverse determination and how
TDI assigns a request for independent review to an IRO.
(2) Existence of life-threatening condition.
An injured employee, the injured employee's representative, or the injured
employee's provider of record must determine the existence of a
life-threatening condition on the basis that a prudent layperson possessing an
average knowledge of medicine and health would believe that the injured
employee's disease or condition is a life-threatening condition.
(3) Appeal of adverse determination involving
life-threatening condition. Any party who receives an adverse determination
involving a life-threatening condition or whose appeal of an adverse
determination involving a life-threatening condition is denied by the URA may
seek review of the adverse determination by an IRO assigned under Insurance
Code Chapter 4202 and Chapter 12 of this title (relating to Independent Review
Organizations).
(b) Independent review involving life-threatening and non life-threatening conditions. A URA, or insurance carrier that made the adverse determination, must notify TDI within one working day from the date a request for an independent review is received. The URA, or insurance carrier that made the adverse determination, must submit the completed request for a review by an IRO form to TDI through TDI's Internet website.
(1) Assignment of IRO. Within one working day
of receipt of a complete request for independent review, TDI will randomly
assign an IRO to conduct the independent review and notify the URA, the payor,
the IRO, the injured employee or the injured employee's representative, injured
employee's provider of record and any other providers listed by the URA as
having records relevant to the review of the assignment.
(2) Workers' compensation non-network
coverage. Additional requirements for independent review of an adverse
determination for a workers' compensation non-network coverage review are
governed by the Texas Workers' Compensation Act and TDI-DWC rules, including
but not limited to Chapter 133, Subchapter D, of this title (relating to
Dispute of Medical Bills).
(3)
Workers' compensation network coverage. Additional requirements for independent
review of an adverse determination for a workers' compensation network coverage
review are governed by Insurance Code Chapter 1305, TDI rules, and TDI-DWC
rules, including but not limited to Chapter 10, Subchapter F, of this title
(relating to Utilization Review and Retrospective Review) and Chapter 133,
Subchapter D, 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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