Texas Register, Volume 22, Number 80, Pages 12189-12342, December 12, 1997 Page: 12,264
12189-12342 p. ; 28 cm.View a full description of this periodical.
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19.1702(b). One commenter suggested that the rules clarify
at the beginning of this section whether a Health Maintenance
Organization (HMO) must obtain a license as a utilization review
agent.
Response. The department agrees and has added clarifying
language in 19.1702(b) requiring the filing of documentation
with the department to assure compliance with the Act as set
forth in 19.1719. The department has made changes to clarify
that the name, address, contact name, phone number and
utilization review plan of the health maintenance organization
is to be submitted.
19.1702(c), 19.1705 and 19.1719(b)(1). Several commenters
suggested that there may be possible conflicts between the La-
bor Code, Title 5, the Texas Workers' Compensation Commis-
sion rules, and these proposed sections. One commenter asked
if the spinal surgery second opinion process, as outlined in the
Texas Labor Code and Texas Workers' Compensation Commis-
sion rules conflicts with the proposed Chapter 19 rules. A com-
menter questioned whether the Texas Workers' Compensation
Commission medical dispute resolution process conflicts with
TDI provisions governing appeals and/or written procedures.
Some commentors suggested that the deletion of the language
excluding workers' compensation from the scope of the rules
either be postponed until such time as rules for workers' com-
pensation may be adopted or that language be added to clarify
that the utilization review rules are not applicable to workers'
compensation until additional rules are adopted. The commen-
tors stated that the inclusion of these provisions could create
ambiguity and misunderstanding as to the appropriate utiliza-
tion review requirements for workers' compensation.
One commenter asked whether the Texas Labor Code Section
413.011(a)(2), concerning treatment guidelines, conflicts with
proposed 19.1705(3). The commenter also asked that the
agency clarify whether the limitation on the liability of workers'
compensation carriers for medical benefits established by Texas
Labor Code Section 408.021 conflicts with proposed 19.1705.
One commenter asked that the department clarify whether
the department intends proposed 19.1719(b)(1) to apply to a
workers' compensation carrier that delivers or issues for delivery
a workers' compensation policy in Texas and performs utilization
review.
Response. The department has deleted language proposed
in 19.1702(c), regarding the authority of the Texas Workers'
Compensation Commission, and has renumbered the remaining
subsection accordingly. It has also added language stating that
the subchapter does not apply to review of health care services
provided to patients under the authority of the Texas Workers'
Compensation Act. This change is made pursuant to House Bill
3197, 75th Texas Legislature, which amended the Insurance
Code Article 21.58A to require regulation of utilization review
of a medical benefit under the Workers' Compensation Act,
but which states it does not affect the authority of the Texas
Workers' Compensation Commission to exercise the powers
granted under its statute, which prevails in the event of a
conflict. Accordingly, the department, in cooperation with the
Texas Workers' Compensation Commission, will propose rules
specific to workers' compensation utilization review, which will
specify which provisions of the Insurance Code Article 21.58A
apply to such review, and which provisions are in conflict with
the Texas Workers' Compensation Act and therefore subject to
the latter statute.19.1702(d)(3)(B). One commenter suggested that the rules
be clarified to ensure that the utilization review rules apply to
the Primary Care Case Management (PCCM) program. The
commenter stated that the Medicaid PCCM managed care
utilization review activities are essentially similar to the utilization
reviews performed by HMOs and are performed for the Texas
Medicaid program by contract with an agency operating part
of the state Medicaid managed care program. The commenter
also noted that in some Medicaid service areas PCCM is a
larger managed care system than the HMO model.
Response. The department disagrees. The Primary Care Case
Management model is a state administered model and does not
fall within the definition of an HMO. The Medicaid program is
specifically exempted from compliance with the Act.
19.1703 Adverse Determination. One commenter recom-
mended using the definition of adverse determination found in
Senate Bills 384 and 386.
Response. The department believes that the definition of "ad-
verse determination" complies with the legislative intent of Sen-
ate Bills 384 and 386 by clarifying that all adverse determi-
nations, whether based on medical necessity or appropriate-
ness of the recommended treatment, are subject to the appeals
process and independent review. The department wants to en-
sure that the utilization review process is not used to ration
health care by denying treatment simply because it is costly.
19.1703. Emergency Care. One commenter requested
that the "emergency care" definition clarify what would be
considered "recent onset," and asked whether the definition
excludes care rendered in an inpatient setting. The commenter
requested additional guidance as to how the components of the
definition apply to behavioral health services.
Response. The phrase "recent onset and severity" indicates
that the patient's condition reached a severity level such that
the patient would be led, as a prudent layperson, to believe that
immediate medical care was needed. The department believes
that the language is clear, yet not restrictive. The definition of
emergency care primarily includes care rendered in a hospital
emergency room setting.
19.1703. Life-threatening. Two commentors recommended
that the department clarify the applicability of the definition of
"life-threatening" to behavioral health services. One commenter
suggested amending the definition of "life-threatening" to in-
clude language that the likelihood of death is probable and im-
minent unless the course of the disease or condition is imme-
diately interrupted.
Response. The department is reviewing the statutory definitions
in relation to behavioral health services and is working with the
Texas Department of Mental Health and Mental Retardation to
develop guidelines for behavioral health services. The definition
of "life-threatening" is statutory and the department does not
believe that clarifying language is necessary.
19.1703. Open Records Law. One commenter suggested that
the word "patient" seems to have been inadvertently included.
Response. The reason for the comment is unclear, as it
does not appear that the published rule included "patient"
inappropriately.
19.1704. One commenter suggested that the section require
additional items to be submitted for continued licensure. The
commenter inquired whether the other items must be furnished22 TexReg 12264 December 12, 1997 Texas Register
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Texas. Secretary of State. Texas Register, Volume 22, Number 80, Pages 12189-12342, December 12, 1997, periodical, December 12, 1997; Austin, Texas. (https://texashistory.unt.edu/ark:/67531/metapth176721/m1/78/: accessed July 18, 2024), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu; crediting UNT Libraries Government Documents Department.