(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) Adverse determination--A determination by a URA
made on behalf of a payor that the health care services provided or
proposed to be provided to an injured employee are not medically necessary
or appropriate. The term does not include a denial of health care
services due to the failure to request prospective or concurrent utilization
review. For the purposes of this subchapter, an adverse determination
does not include a determination that health care services are experimental
or investigational.
(2) Appeal--The URA's formal process by which an injured
employee, an injured employee's representative, or an injured employee's
provider of record may request reconsideration of an adverse determination.
For the purposes of this subchapter the term also applies to reconsideration
processes prescribed by Labor Code Title 5 and applicable rules for
workers' compensation.
(3) Biographical affidavit--National Association of
Insurance Commissioners biographical affidavit to be used as an attachment
to the URA application.
(4) Certificate--A certificate issued by the commissioner
to an entity authorizing the entity to operate as a URA in the State
of Texas. A certificate is not issued to an insurance carrier that
is registered as a URA under §19.2004 of this title (relating
to Certification or Registration of URAs).
(5) Commissioner--As defined in Insurance Code §31.001.
(6) Compensable injury--As defined in Labor Code §401.011.
(7) Complaint--An oral or written expression of dissatisfaction
with a URA concerning the URA's process in conducting a utilization
review. The term "complaint" does not include:
(A) an expression of dissatisfaction constituting an
appeal under Insurance Code §4201.351; or
(B) a misunderstanding or misinformation that is resolved
promptly by supplying the appropriate information or by clearing up
the misunderstanding to the satisfaction of the complaining party.
(8) Concurrent utilization review--A form of utilization
review for ongoing health care or for an extension of treatment beyond
previously approved health care.
(9) Disqualifying association--Any association that
may reasonably be perceived as having potential to influence the conduct
or decision of a reviewing physician, doctor, or other health care
provider, which may include:
(A) shared investment or ownership interest;
(B) contracts or agreements that provide incentives,
for example, referral fees, payments based on volume or value, or
waiver of beneficiary coinsurance and deductible amounts;
(C) contracts or agreements for space or equipment
rentals, personnel services, management contracts, referral services,
or warranties, or any other services related to the management of
a physician's, doctor's, or other health care provider's practice;
(D) personal or family relationships; or
(E) any other financial arrangement that would require
disclosure under Labor Code or applicable TDI-DWC rules, Insurance
Code or applicable TDI rules, or any other association with the injured
employee, employer, or insurance carrier that may give the appearance
of preventing the reviewing physician, doctor, or other health care
provider from rendering an unbiased opinion.
(10) Doctor--As defined in Labor Code §401.011.
(11) Experimental or investigational--A health care
treatment, service, or device for which there is early, developing
scientific or clinical evidence demonstrating the potential efficacy
of the treatment, service, or device but that is not yet broadly accepted
as the prevailing standard of care.
(12) Health care--As defined in Labor Code §401.011.
(13) Health care facility--As defined in Labor Code §401.011.
(14) Insurance carrier or insurer--As defined in Labor
Code §401.011.
(15) Independent review organization or IRO--As defined
in §12.5 of this title (relating to Definitions).
(16) Legal holiday--
(A) a holiday as provided in Government Code §662.003(a);
(B) the Friday after Thanksgiving Day;
(C) December 24; and
(D) December 26.
(17) Medical benefit--As defined in Labor Code §401.011.
(18) Medical emergency--The sudden onset of a medical
condition manifested by acute symptoms of sufficient severity, including
severe pain that the absence of immediate medical attention could
reasonably be expected to result in:
(A) placing the injured employee's health or bodily
functions in serious jeopardy; or
(B) serious dysfunction of any body organ or part.
(19) Medical records--The history of diagnosis of and
treatment for an injury, including medical, mental health records
as allowed by law, dental, and other health care records from all
disciplines providing care to an injured employee.
(20) Mental health medical record summary--A summary
of process or progress notes relevant to understanding the injured
employee's need for treatment of a mental or emotional condition or
disorder including:
(A) identifying information; and
(B) a treatment plan that includes a:
(i) diagnosis;
(ii) treatment intervention;
(iii) general characterization of injured employee
behaviors or thought processes that affect level of care needs; and
(iv) discharge plan.
(21) Mental health therapist--Any of the following
individuals who, in the ordinary course of business or professional
practice, as appropriate, diagnose, evaluate, or treat any mental
or emotional condition or disorder:
(A) an individual licensed by the Texas Medical Board
to practice medicine in this state;
(B) an individual licensed as a psychologist, psychological
associate, or a specialist in school psychology by the Texas State
Board of Examiners of Psychologists;
(C) an individual licensed as a marriage and family
therapist by the Texas State Board of Examiners of Marriage and Family
Therapists;
(D) an individual licensed as a professional counselor
by the Texas State Board of Examiners of Professional Counselors;
(E) an individual licensed as a social worker by the
Texas State Board of Social Worker Examiners;
(F) an individual licensed as a physician assistant
by the Texas Medical Board;
(G) an individual licensed as a registered professional
nurse by the Texas Board of Nursing; or
(H) any other individual who is licensed or certified
by a state licensing board in the State of Texas, as appropriate,
to diagnose, evaluate, or treat any mental or emotional condition
or disorder.
(22) Mental or emotional condition or disorder--A mental
or emotional illness as detailed in the most current Diagnostic and
Statistical Manual of Mental Disorders.
(23) Payor--Any person or entity that provides, offers
to provide, or administers hospital, outpatient, medical, or other
health benefits, including workers' compensation benefits, to an individual
treated by a health care provider under a policy, plan, statute, or
contract.
(24) Peer review--An administrative review by a health
care provider performed at the insurance carrier's request without
a physical examination of the injured employee.
(25) Person--Any individual, partnership, association,
corporation, organization, trust, hospital district, community mental
health center, mental retardation center, mental health and mental
retardation center, limited liability company, limited liability partnership,
a political subdivision of this state, the statewide rural health
care system under Insurance Code Chapter 845, and any similar entity.
(26) Preauthorization--A form of prospective utilization
review by a payor or a payor's URA of health care services proposed
to be provided to an injured employee.
(27) Provider of record--The physician, doctor, or
other health care provider that has primary responsibility for the
health care services rendered or requested on behalf of an injured
employee, or a physician, doctor, or other health care provider that
has rendered or has been requested to provide health care services
to an injured employee. This definition includes any health care facility
where health care services are rendered on an inpatient or outpatient
basis.
(28) Reasonable opportunity--At least one documented
good faith attempt to contact the provider of record that provides
an opportunity for the provider of record to discuss the services
under review with the URA during normal business hours prior to issuing
a prospective, concurrent, or retrospective utilization review adverse
determination:
(A) no less than one working day prior to issuing a
prospective utilization review adverse determination;
(B) no less than five working days prior to issuing
a retrospective utilization review adverse determination; or
(C) prior to issuing a concurrent or post-stabilization
review adverse determination.
(29) Registration--The process for an insurance carrier
to register with TDI to perform utilization review solely for injured
employees covered by workers' compensation insurance coverage issued
by the insurance carrier.
(30) Request for a review by an IRO--Form to request
a review by an independent review organization that is completed by
the requesting party and submitted to the URA, or insurance carrier
that made the adverse determination.
(31) Retrospective utilization review--A form of utilization
review for health care services that have been provided to an injured
employee. Retrospective utilization review does not include review
of services for which prospective or concurrent utilization reviews
were previously conducted or should have been previously conducted.
(32) Screening criteria--The written policies, decision
rules, medical protocols, or treatment guidelines used by a URA as
part of the utilization review process.
(33) TDI--The Texas Department of Insurance.
(34) TDI-DWC--The Texas Department of Insurance, Division
of Workers' Compensation.
(35) Texas Workers' Compensation Act--Labor Code Title
5, Subtitle A.
(36) Treating doctor--As defined in Labor Code §401.011.
(37) URA--Utilization review agent.
(38) URA application--Form for application for, renewal
of, and reporting a material change to a certification or registration
as a URA in this state.
(39) Workers' compensation health care network--As
defined in Insurance Code §1305.004.
(40) Workers' compensation health plan--Health care
provided by a political subdivision contracting directly with health
care providers or through a health benefits pool, under Labor Code §504.053(b)(2).
(41) Workers' compensation insurance coverage--As defined
in Labor Code §401.011.
(42) Workers' compensation network coverage--Health
care provided under a workers' compensation health care network.
(43) Workers' compensation non-network coverage--Health
care delivered under Labor Code Title 5, excluding health care provided
under Insurance Code Chapter 1305.
Source Note: The provisions of this §19.2003 adopted to be effective February 20, 2013, 38 TexReg 892
