1. (a) An independent review organization shall notify the patient or a representative of the patient, the patient's provider of record, the utilization review agent, the payor, and the department of a determination made in an independent review.

2. (b) The notification required by this section must be mailed or otherwise transmitted not later than the earlier of:

   1. (1) The 15th day after the date the independent review organization receives the information necessary to make a determination; or
   2. (2) the 20th day after the date the independent review organization receives the request for the independent review.

3. (c) In the case of a life-threatening condition, the notification must be by telephone to be followed by facsimile, electronic mail, or other method of transmission not later than the earlier of:

   1. (1) the 5th day after the date the independent review organization receives the information necessary to make a determination; or
   2. (2) the 8th day after the date the independent review organization receives the request for independent review.

4. (d) Notification of determination by the independent review organization is required to include at a minimum:

   1. (1) a listing of all recipients of the notification of determination as described in subsection (a) of this section, identifying for each:

      1. (A) the name; and

      2. (B) as applicable to the manner of transmission used to issue the notification of determination to the recipient:

         1. (i) mailing address;
         2. (ii) facsimile number; or
         3. (iii) electronic mail address;
   2. (2) the date of the original notice of the decision, and if amended for any reason, the date of the amended notification of decision;
   3. (3) the independent review case number assigned by the department;
   4. (4) the name of the patient;
   5. (5) a statement of whether the type of coverage is health insurance, workers' compensation, or workers' compensation health care network;
   6. (6) a statement of whether the context of the review is preauthorization, concurrent utilization review, or retrospective utilization review of health care services;
   7. (7) the name and certificate number of the independent review organization;
   8. (8) a description of the services in dispute;
   9. (9) a complete list of the information provided to the independent review organization for review, including dates of service and document dates where applicable;
   10. (10) a description of the qualifications of the reviewing physician or provider;

   11. (11) a statement that the review was performed without bias for or against any party to the dispute and that the reviewing physician or provider has certified that no known conflicts of interest exist between the reviewer and:

       1. (A) the patient;
       2. (B) the patient's employer, if applicable;
       3. (C) the insurer;
       4. (D) the utilization review agent;
       5. (E) any of the treating physicians or providers; or
       6. (F) any of the physicians or providers who reviewed the case for determination prior to referral to the independent review organization, and that the review was performed without bias for or against any party to the dispute;
   12. (12) a statement that the independent review was performed by a health care provider licensed to practice in Texas if required by applicable law and of the appropriate professional specialty;

   13. (13) a statement that there is no known conflict of interest between the reviewer, the IRO, and/or any officer or employee of the IRO with:

       1. (A) the patient;
       2. (B) the provider requesting independent review;
       3. (C) the provider of record;
       4. (D) the utilization review agent;
       5. (E) the payor; and
       6. (F) the certified workers' compensation health care network, if applicable;
   14. (14) a summary of the patient's clinical history;
   15. (15) the review outcome, clearly stating whether or not medical necessity or appropriateness exists for each of the health care services in dispute and whether the health care services in dispute are experimental or investigational, as applicable;
   16. (16) a determination of the prevailing party if applicable;
   17. (17) the analysis and explanation of the decision, including the clinical bases, findings and conclusions used to support the decision;
   18. (18) a description and the source of the review criteria that were utilized to make the determination;
   19. (19) a certification by the independent review organization of the date that the decision was sent to all of the recipients of the notification of determination as required in subsection (a) of this section via U.S. Postal Service or otherwise transmitted in the manner indicated on the form; and
   20. (20) for independent reviews of health care services provided under the Labor Code Title 5 or the Insurance Code Chapter 1305, any information required by §133.308 of this title (relating to MDR by Independent Review Organizations); and
   21. (21) notice of applicable appeal rights under the Insurance Code Chapter 1305 and the Labor Code Title 5, and instructions concerning requesting such appeal.
5. (e) Example templates for the notification of determination regarding health and workers' compensation cases may be found on the department's website at http://www.tdi.state.tx.us/forms.

Source Note:The provisions of this §12.206 adopted to be effective November 26, 1997, 22 TexReg 11363; amended to be effective December 26, 2010, 35 TexReg 11281.