Texas Register, Volume 37, Number 34, Pages 6391-6818, August 24, 2012 Page: 6,483
6391-6818 p. ; 28 cm.View a full description of this periodical.
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coverage these proposed sections are to be applied in tandem
with TDI's rules concerning workers' compensation health care
networks and with TDI-DWC's rules concerning general medical
procedures.
Section 19.1717(c)(2) specifies that the payor, in addition to the
URA, must comply with the IRO's determination. This new rule
is necessary to clarify that payors must also comply with the
IRO's determination, because sometimes the URA and the payor
are different parties. This provision implements Insurance Code
4201.401. Section 19.1717(c)(3) retains the requirements in
existing 19.1721(j) and (k) and implements Insurance Code
4201.403.
Section 19.1718 addresses Preauthorization for Health Main-
tenance Organizations and Preferred Provider Benefit Plans
and implements Insurance Code 843.348, 1301.135, and
4201.304. Section 19.1718(a) clarifies that the words and terms
used in Insurance Code Chapter 1301 and Chapter 843 have
the same meaning when used in 19.1718. Section 19.1718(b)
retains the requirements in existing 19.1723(a), which track the
requirements in Insurance Code 843.348. Section 19.1718(c)
and 19.1718(f)(2) do not use the term "business day," as used
in existing 19.1723(b) and (f)(2), but instead use the term
"working day" for consistency with the other rule provisions
that contain the "working day" requirement. The requirements
in existing 19.1723(c) are not included in the proposed new
rules because the requirements are found in Insurance Code
843.348(e) and inclusion of the requirements would be repeti-
tive. Section 19.1718(d) - (i) retain the requirements in existing
19.1723(d) - (i).
Section 19.1718(d)(2) adds a requirement that the initial deter-
mination by an HMO or preferred provider benefit plan indicat-
ing whether proposed services are preauthorized within 24 hours
of receipt of the request must be followed, within three working
days, by a letter notifying the enrollee or the individual acting
on behalf of the enrollee and the provider of record of an ad-
verse determination. This requirement is necessary to ensure
that prompt written documentation of the adverse determination
is provided to the relevant parties.
Section 19.1719 addresses Verification for Health Maintenance
Organizations and Preferred Provider Benefit Plans and imple-
ments Insurance Code 843.347, 1301.133, and 4201.304.
Section 19.1719(a) clarifies that the words and terms used
in Insurance Code Chapter 1301 and Chapter 843 have the
same meaning when used in 19.1719. Section 19.1719(a) -
(c) retain the requirements in existing 19.1724(a) - (c). The
requirements in existing 19.1724(d) are not included in the
proposed new rules because the requirements are in Insurance
Code 843.347(h) and (i), and inclusion of the requirements
would be repetitive. Section 19.1719(d) - (i) retain the require-
ments in existing 19.1724(e) - (k). The requirements in existing
19.1724(l) and (m) are not included in the proposed new rules
because the requirements are in Insurance Code 1301.133(g)
and (h), and inclusion of the requirements would be repetitive.
FISCAL NOTE. Debra Diaz-Lara, Director, Managed Care Qual-
ity Assurance Office, has determined that for each year of the
first five years the proposed new sections will be in effect, there
will be no fiscal impact to state and local governments because
of the enforcement or administration of the proposal. There will
be no measurable effect on local employment or the local econ-
omy because of the proposal.PUBLIC BENEFIT/COST NOTE. Ms. Diaz-Lara also has de-
termined that for each year of the first five years the proposed
new sections are in effect, there are several public benefits an-
ticipated because of the enforcement and administration of the
proposal, as well as potential costs for persons required to com-
ply with the proposal. TDI drafted the proposed rules to maxi-
mize public benefits consistent with the intent of the authorizing
statutes while mitigating costs.
ANTICIPATED PUBLIC BENEFITS
The anticipated public benefits in general are (i) the updating
of existing rules regulating URAs to comply with legislation en-
acted by the 81st Legislature; (ii) clarification of existing rules to
facilitate compliance, implementation, and enforcement of these
rules; and (iii) an improved regulatory framework for URAs.
Compliance with legislation. The anticipated public benefits of
the proposed new rules related to compliance with legislation in-
clude the establishment of a regulatory framework that supports
the operation of a URA. The new rules are in compliance with
the requirements of HB 4290, 81st Legislature, Regular Session,
effective September 1, 2009, which effectively revises the defini-
tion of "adverse determination" in Insurance Code Chapter 4201
to include retrospective reviews and determinations regarding
the experimental or investigational nature of a service. These
new rules will assist health care consumers by providing for a re-
view of claims that could otherwise be denied without recourse.
Clarification of existing rules. Additionally, the anticipated pub-
lic benefits of the proposed new rules related to clarification of
existing rules are: (i) consistency of terminology throughout the
text for readability and ease of understanding; (ii) increased clar-
ity concerning the evidence-based or generally accepted stan-
dards on which a URA must base its screening criteria, which
will result in valid and sound decisions because credible and
scientific guidelines are used and will also result in increased
confidence in the URA's decisions; (iii) updated references and
citations for readability and ease of understanding; (iv) increased
clarity in existing rules to assist persons applying for or renewing
a certificate of registration; (v) increased clarity concerning con-
fidentiality requirements to better protect the enrollee's or injured
employee's health care information; (vi) enhanced oversight of
URAs that will result in better and more efficient compliance with
requirements; and (vii) improved telephone access to URAs that
will provide health care consumers with easier and more efficient
access to URAs.
Other anticipated public benefits of the proposed new rules re-
lated to clarification of existing rules are: (i) establishment of
standards for the review of the medical necessity or appropri-
ateness of health care services by health care providers of the
appropriate specialty, which will result in utilization review by
the appropriate personnel; (ii) the establishment of a standard-
ized complaint process for consumers for easier and more ef-
ficient resolution of their oral or written complaints concerning
the utilization review; (iii) greater transparency concerning the
documentation or evidence, if any, that can be submitted by the
provider of record that on appeal might lead to a different uti-
lization review decision; (iv) standards for the determination of a
life-threatening condition to be made by the prudent layperson
standard, permitting consumers to have determinations made in
a timely manner when life-threatening conditions exist; (v) ex-
panding the preauthorization decision regarding facility-based
surgeries to include necessary pain medication, which reduces
the risk that an injured employee would be unable to obtain nec-
essary pain medications after surgery through their approvedPROPOSED RULES August 24, 2012 37 TexReg 6483
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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/m1/92/: accessed March 28, 2024), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu; crediting UNT Libraries Government Documents Department.