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 advisor 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, health insurance carrier, health maintenance organization, or managed care entity requesting the independent review shall be responsible for timely delivering to and ensuring receipt by the independent review organization any written narrative supplied by the patient pursuant to Insurance Code, Article 21.58A. However, in instances of emergency or life-threatening condition, the independent review organization shall contact the patient or person acting on behalf of the patient, and provider directly.
4. (d) An independent review organization shall notify the department within 24 hours of receipt of information regarding an independent review from the requesting utilization review agent, health insurance carrier, health maintenance organization, or managed care entity that such documents have been delivered and the date of such delivery.
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 requested patient records or other documents. 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 the Texas Workers' Compensation Commission 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, or managed care entity requesting the review as an expense of independent review.
6. (f) When conducting independent review, the independent review organization shall collect any information necessary to review the adverse determination not already provided by the utilization review agent, health insurance carrier, health maintenance organization, or managed care entity. This information may include identifying information about the patient, the benefit plan, the treating health care provider, and/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; and/or the treatment plan prescribed by the treating health care provider along with the provider's justification for the treatment plan.
7. (g) The independent review organization should 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.