130.1
(a) Authorized Doctor. (1) Only an authorized doctor may certify maximum medical improvement (MMI), determine whether there is permanent impairment, and assign an impairment rating if there is permanent impairment. (A) Doctors serving in the following roles may be authorized as provided in subsection (a)(1)(B) of this section. (i) the treating doctor (or a doctor […]
19.2001
(a) Statutory basis. This subchapter implements Insurance Code Chapter 4201, concerning Utilization Review Agents; Insurance Code Chapter 1305, concerning Workers’ Compensation Health Care Networks; and Labor Code Title 5, concerning Workers’ Compensation. (b) Severability. If a court of competent jurisdiction holds that any provision of this subchapter or its application to any person or circumstance […]
19.2002
(a) Limitations on applicability. Except as provided in Insurance Code Chapter 4201, this subchapter applies to utilization review performed under workers’ compensation insurance coverage. This subchapter does not affect the authority of TDI-DWC to exercise the powers granted to it under Labor Code Title 5 and Insurance Code Chapter 4201. This subchapter applies to utilization […]
19.2003
(a) The words and terms defined in Insurance Code Chapter 4201 have the same meaning when used in this subchapter, except as otherwise provided by this subchapter, unless the context clearly indicates otherwise. (b) The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise. (1) […]
19.2005
(a) Review of utilization review plan. A utilization review plan must be reviewed and approved by a physician and conducted under standards developed and periodically updated with input from both primary and specialty physicians, doctors, and other health care providers, including practicing health care providers, as appropriate. (b) Special circumstances. A utilization review determination must […]
19.2006
(a) Qualification requirements. Physicians, doctors, and other health care providers employed by or under contract with a URA to perform utilization review must be appropriately trained, qualified, and currently licensed. Personnel conducting utilization review must hold an unrestricted license or an administrative license in Texas or be otherwise authorized to provide health care services in […]
19.2007
(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 […]
19.2008
(a) Identification of URAs. If a URA’s staff member is conducting an on-site or off-site review, each staff member must provide his or her name, the name of his or her organization, photo identification, and a URA identification card with the certification or registration number assigned by TDI when requested by an individual, including an […]
19.2009
(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, […]
19.2010
In any instance in which a 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, dentist, or chiropractor. If the […]