Independent review shall be conducted in accordance with an independent review plan that is consistent with standards developed with input from appropriate health care providers, and reviewed and approved by a physician. The independent review plan shall include the following components:

1. (1) A description of the elements of review which the independent review organization provides;

2. (2) written procedures for:

   1. (A) notification of the independent review organization's determinations provided to the patient or a representative of the patient, the patient's provider of record, and the utilization review agent, in accordance with §12.206 of this subchapter (relating to Notice of Determinations Made by Independent Review Organizations);

   2. (B) review, including:

      1. (i) any form used during the review process;
      2. (ii) timeframes that shall be met during the review;
   3. (C) accessing appropriate specialty review;
   4. (D) contacting and receiving information from health care providers in accordance with §12.205 of this subchapter (relating to Independent Review Organization Contact with and Receipt of Information from Health Care Providers and Patients);

3. (3) required use of written medically acceptable review criteria that are:

   1. (A) based on medical and scientific evidence and utilize evidence-based standards, or if evidence is not available, generally accepted standards of medical practice recognized in the medical community;
   2. (B) established and periodically evaluated and updated with appropriate involvement from physicians, including practicing physicians, and other health care providers;
   3. (C) objective, clinically valid, compatible with established principles of health care, and flexible enough to allow deviations from the norms when justified on a case-by-case basis;
   4. (D) developed based on consideration of the treatment guidelines, treatment protocols, and pharmacy closed formulary as provided in orders issued or rules adopted by TDI-DWC, including Chapter 134 of this title (relating to Benefits--Guidelines for Medical Services, Charges, and Payments) and Chapter 137 of this title (relating to Disability Management) for health care provided pursuant to the Labor Code Title 5;
   5. (E) used only as a tool in the review process; and
   6. (F) available for review, inspection, and copying as necessary by the commissioner or the commissioner's designated representative in order for the commissioner to carry out the commissioner's lawful duties under the Insurance Code;

4. (4) independent review determinations that:

   1. (A) utilize review procedures that are established and periodically evaluated and updated with appropriate involvement from physicians, including practicing physicians, and other health care providers;
   2. (B) are made in accordance with medically accepted review criteria, taking into account the special circumstances of each case that may require a deviation from the norm; and
   3. (C) are made by physicians, dentists, or other health care providers, as appropriate.

Source Note:The provisions of this §12.201 adopted to be effective November 26, 1997, 22 TexReg 11363; amended to be effective December 26, 2010, 35 TexReg 11281.