Texas Register, Volume 37, Number 34, Pages 6391-6818, August 24, 2012 Page: 6,468
6391-6818 p. ; 28 cm.View a full description of this periodical.
Extracted Text
The following text was automatically extracted from the image on this page using optical character recognition software:
TDI-DWC's medical billing rules or otherwise modify insurance
carrier's duties under those rules.
To implement Insurance Code 4201.054(c), 19.2002(b)(3)
provides that if there is a conflict between Subchapter U and
rules adopted by the commissioner of workers' compensation,
the rules adopted by the commissioner of workers' compen-
sation prevail. These required new rules are consistent with
Insurance Code 4201.054(a), which provides that except as
provided by 4201.054, Chapter 4201 applies to utilization
review of a health care service provided to a person eligible
for workers' compensation medical benefits under Labor Code
Title 5. Additionally, Insurance Code 4201.054(c) provides that
Labor Code Title 5 prevails in the event of a conflict between
Chapter 4201 and Labor Code Title 5.
Section 19.2002(b)(4) provides that if there is a conflict between
the URA rules and the certified health care network rules
adopted by TDI, the rules adopted for networks in 28 TAC
Chapter 10 prevail. The rules for workers' compensation health
care networks in 28 TAC Chapter 10 implement Insurance Code
Chapter 1305. Insurance Code 1305.351(a) provides that in
the event of a conflict between Chapter 4201 and Chapter 1305,
Chapter 1305 prevails.
Section 19.1703 and 19.2003 address Definitions. Section
19.1703(a) and 19.2003(a) provide that the terms defined
in Insurance Code Chapter 4201 have the same meaning as
used in proposed new Subchapter R and Subchapter U rules,
respectively.
The definition of "adverse determination" in 19.1703(b)(1) and
19.2003(b)(1) add the phrase "made on behalf of any payor"
to the definition of "adverse determination" in existing Insurance
Code 4201.002(1) to clarify TDI's position that the definition in-
cludes determinations made on behalf of all payors, including
payors that conduct utilization review in-house.
Further, the definitions of "adverse determination" in Subchap-
ters R and U specifically implement HB 4290. Insurance Code
4201.002(1) defined "adverse determination," prior to the en-
actment of HB 4290, to mean a URA's determination that health
care services provided or proposed to be provided to a patient
are not medically necessary or appropriate, but the provision
was not interpreted to include retrospective review of medical
necessity. This interpretation was based on the definition of "uti-
lization review" in Insurance Code 4201.002(13) as a system
for "prospective or concurrent" review of the medical necessity
and appropriateness of health care services being provided or
proposed to be provided to an individual in this state. After the
enactment of HB 4290, the definitions of "adverse determination"
and "utilization review" were revised in Insurance Code Chap-
ter 4201 to include retrospective reviews and determinations re-
garding the experimental or investigational nature of a service.
Additionally, 19.1703(b)(1) and 19.2003(b)(1) add the provi-
sion that the term "adverse determination" does not include a
denial of health care services due to the lack of prospective or
concurrent utilization review. This change is necessary to clarify
that a denial of health care services for which the enrollee or in-
jured employee, respectively, should have sought prospective or
concurrent utilization review is not within the scope of the term.
The definition in 19.2003(b)(1) also clarifies that, for the pur-
poses of Subchapter U, an adverse determination does not
include a determination that health care services are experimen-
tal or investigational. Although this clarification is inconsistent
with the statutory definition of "adverse determination" underInsurance Code 4201.002(1), it is consistent with Labor Code
408.021 and 413.014. Insurance Code 4201.054 provides
that, in the event of a conflict, Labor Code Title 5 prevails. It
is TDI's and TDI-DWC's position that based on Labor Code
408.021, an injured employee under both network and non-net-
work coverage is entitled to all medically necessary health care
services, including experimental and investigational health care
services.
Labor Code 408.021 entitles an injured employee, under both
network coverage and non-network coverage, to all medically
necessary health care services. Although injured employees
under non-network coverage are entitled to experimental and
investigational services, those services must be preauthorized
under Labor Code 413.014, relating to preauthorization require-
ments, concurrent review, and certification of health care.
Despite this difference in the definition of the term "adverse
determination" under Insurance Code Chapter 4201 and Labor
Code Chapter 408, it is necessary that Subchapter U contain
provisions relating to the experimental or investigational nature
of care in the context of utilization review. Even though the
determination that a health care service is experimental or
investigational does not in itself constitute an adverse deter-
mination, only a URA should make determinations that health
care services are experimental or investigational, based on the
definition of "utilization review."
The definition of "appeal" in 19.1703(b)(2) and 19.2003(b)(2)
updates the existing definition and clarifies that the term refers to
the URA's formal process in which an enrollee, or an injured em-
ployee, respectively, their representative, or provider of record
may request reconsideration of an adverse determination. Sec-
tion 19.2003(b)(2) also provides that the term includes reconsid-
eration processes prescribed by Labor Code Title 5 and applica-
ble rules for workers' compensation.
The definition of the term "certificate" in 19.1703(b)(3) and
19.2003(b)(3) is more detailed and accurate than the existing
definition to reflect that an insurance carrier or HMO may be
certified or registered, but that a "certificate" is not issued to
an insurance carrier or HMO that is registered as a URA under
19.1704 or 19.2004, respectively.
The 19.1703(b)(4) and 19.2003(b)(4) definition of "commis-
sioner" is defined in Insurance Code 31.001, which provides
that "In this code and other insurance laws: (1) "Commissioner"
means the commissioner of insurance."
In 19.2003(b)(5), the term "compensable injury" is as defined in
Labor Code 401.011, which provides that "Compensable injury
means an injury that arises out of and in the course and scope of
employment for which compensation is payable under this sub-
title."
Section 19.1703(b)(5) and 19.2003(b)(6) define "complaint"
as 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. This definition is necessary to track
statutory language in Insurance Code 4201.351 and clarify
that a misunderstanding promptly resolved, to the complaining
parties' satisfaction, does not constitute disagreement with an
adverse determination or an appeal.37 TexReg 6468 August 24, 2012 Texas Register
Upcoming Pages
Here’s what’s next.
Search Inside
This issue can be searched. Note: Results may vary based on the legibility of text within the document.
Tools / Downloads
Get a copy of this page or view the extracted text.
Citing and Sharing
Basic information for referencing this web page. We also provide extended guidance on usage rights, references, copying or embedding.
Reference the current page of this Periodical.
Texas. Secretary of State. Texas Register, Volume 37, Number 34, Pages 6391-6818, August 24, 2012, periodical, August 24, 2012; Austin, Texas. (https://texashistory.unt.edu/ark:/67531/metapth253226/m1/77/: accessed April 26, 2024), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu; crediting UNT Libraries Government Documents Department.