1. (a) An independent review organization shall notify the patient or a person acting on behalf 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; and

3. (c) In the case of a life-threatening condition, 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 must include:

   1. (1) the specific reasons, including the clinical basis, for the determination;
   2. (2) a description and the source of the screening criteria that were utilized;
   3. (3) a description of the qualifications of the reviewing physician or provider; and
   4. (4) a certification by the independent review organization that the reviewing physician or provider has certified that no known conflicts of interest exist between him or her and any of the treating physicians or providers or any of the physicians or providers who reviewed the case for determination prior to referral to the independent review organization.

Source Note:The provisions of this §12.206 adopted to be effective November 26, 1997, 22 TexReg 11363.