The independent review plan shall be conducted in accordance 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 person acting on behalf of the patient, the patient's provider of record, and the utilization review agent as addressed in §12.206 of this title (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 title (relating to Independent Review Organization's Contact with and Receipt of Information from Health Care Providers);
3. (3) screening criteria. Each independent review organization shall utilize written medically acceptable screening criteria which are established and periodically evaluated and updated with appropriate involvement from physicians, including practicing physicians, and other health care providers. Such screening criteria must be 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. Screening criteria must only be used as a tool in the review process. Such written screening criteria and review procedures shall be available for review and inspection and copying as necessary by the commissioner or his or her designated representative in order for the commissioner to carry out his or her lawful duties under the Insurance Code;
4. (4) independent review determinations. Each independent review organization shall utilize review procedures which are established and periodically evaluated and updated with appropriate involvement from physicians, including practicing physicians, and other health care providers. Independent review determinations shall be made in accordance with medically accepted screening criteria, taking into account the special circumstances of each case that may require a deviation from the norm. All independent review determinations shall be 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.