1. (a) A health care provider may designate one or more individuals as the initial contact or contacts for independent review organizations seeking routine information or data. In no event shall the designation of such an individual or individuals preclude an independent review organization or medical director from contacting a health care provider or others in his or her employ where a review might otherwise be unreasonably delayed or where the designated individual is unable to provide the necessary information or data requested by the independent review organization.
2. (b) An independent review organization may not engage in unnecessary or unreasonably repetitive contacts with the health care provider or patient and shall base the frequency of contacts or reviews on the severity or complexity of the patient's condition or on necessary treatment and discharge planning activity.
3. (c) In addition to pertinent files containing medical and personal information, the utilization review agent or the health insurance carrier, health maintenance organization, managed care entity, or other payor requesting the independent review shall be responsible for timely delivering to and ensuring receipt by the independent review organization of any written narrative supplied by the patient pursuant to the Insurance Code Chapter 4201 and Chapters 19 and 133 of this title (relating to Agents' Licensing and General Medical Provisions). However, in instances of life-threatening condition, the independent review organization shall contact the patient or representative of the patient, and provider directly.
4. (d) An independent review organization shall notify the department if, within three working days of receipt of the independent review assignment, the independent review organization has not received the pertinent files containing medical and personal information from the requesting utilization review agent or the health insurance carrier, health maintenance organization, managed care entity, or other payor.
5. (e) An independent review organization shall reimburse health care providers for the reasonable costs of providing medical information in writing, including copying and transmitting any patient records or other documents requested by the independent review organization. A health care provider's charge for providing medical information to an independent review organization shall not exceed the cost of copying set by rules of TDI-DWC at §134.120 of this title (relating to Reimbursement for Medical Documentation) for records and may not include any costs that are otherwise recouped as a part of the charge for health care. Such expense shall be reimbursed by the utilization review agent, health insurance carrier, health maintenance organization, managed care entity, or other payor requesting the review as an expense of independent review.
6. (f) Nothing in this section prohibits a patient, the representative of a patient, or a provider of record from submitting pertinent records to an independent review organization conducting independent review.
7. (g) When conducting independent review, the independent review organization shall request and maintain any information necessary to review the adverse determination not already provided by the utilization review agent, health insurance carrier, health maintenance organization, managed care entity, or other payor. This information may include identifying information about the patient, the benefit plan, the treating health care provider, or facilities rendering care. It may also include clinical information regarding the diagnoses of the patient and the medical history of the patient relevant to the diagnoses; the patient's prognosis; or the treatment plan prescribed by the treating health care provider along with the provider's justification for the treatment plan.
8. (h) The independent review organization is required to share all clinical and demographic information on individual patients among its various divisions to avoid duplication of requests for information from patients or providers.

Source Note:The provisions of this §12.205 adopted to be effective November 26, 1997, 22 TexReg 11363; amended to be effective December 26, 2010, 35 TexReg 11281.