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At a Glance:
Section:
10.102
Title:
Notice of Certain Utilization Review Determinations; Preauthorization and Retrospective Review Requirements

§ 10.102

Notice of Certain Utilization Review Determinations; Preauthorization and Retrospective Review Requirements

(a) The preauthorization requirements of Labor Code § 413.014 and rules adopted under that section do not apply to health care provided through a workers' compensation network. If a carrier or network uses a preauthorization process within a network, the requirements of Insurance Code §§ 1305.351--1305.355 and this chapter apply.

(b) Any person performing utilization review or retrospective review for an injured employee receiving health care services in a network shall notify the employee or the employee's representative, if any, and the requesting provider of a determination made in a utilization review or retrospective review.

(c) Notification of an adverse determination must include:

(1) the principal reasons for the adverse determination;

(2) the clinical basis for the adverse determination;

(3) a description of or the source of the screening criteria that were used as guidelines in making the determination;

(4) for any provider consulted, the professional specialty;

(5) a description of the procedure for the reconsideration process; and

(6) notification of the availability of independent review in the form prescribed by the commissioner.

(d) On receipt of a preauthorization request from a provider for proposed services that require preauthorization, the person performing utilization review must issue and transmit a determination indicating whether the proposed health care services are preauthorized, and respond to requests for preauthorization within the periods prescribed by this section.

(e) If the proposed services are for concurrent hospitalization care, the person performing utilization review must, within 24 hours of receipt of the request, transmit a determination indicating whether the proposed services are preauthorized.

(f) If the proposed health care services involve post-stabilization treatment or a life-threatening condition, the person performing utilization review must transmit to the requesting provider a determination indicating whether the proposed services are preauthorized within the time appropriate to the circumstances relating to the delivery of the services and the condition of the patient, not to exceed one hour from receipt of the request. If the person performing utilization review issues an adverse determination in response to a request for post-stabilization treatment or a request for treatment involving a life-threatening condition, the person performing utilization review must provide to the employee or the employee's representative, if any, and the employee's treating provider the notification required under subsection (b) of this section.

(g) For all other requests for preauthorization, the person performing utilization review must issue and transmit the determination under subsection (d) of this section not later than the third calendar day after the date the request is received.

(h) For adverse determinations made pursuant to retrospective review, the adverse determination must be issued in response to a claim for payment consistent with the timelines set forth in Labor Code § 408.027 related to payment of health care providers. An adverse determination issued under this subsection must comply with all applicable requirements related to adverse determinations in this section.

(i) Prescribed forms related to the availability of independent review may be obtained from:

(1) the department's website at www.tdi.state.tx.us; or

(2) the HMO Division, Mail Code 103-6A, Texas Department of Insurance, P.O. Box 149104, Austin, Texas 78714-9104.

The provisions of this § 10.102 adopted to be effective December 5, 2005, 30 TexReg 8099.

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