The following words and terms, when used in this subchapter, shall have the following meanings unless the context clearly indicates otherwise.

1. (1) Act--Insurance Code Article 21.58A, entitled "Health Care Utilization Review Agents."
2. (2) Active practice--A minimum of 20 hours per week in the examination, diagnosis and/or treatment of patients.
3. (3) Administrative Procedure Act--Government Code Chapter 2001.
4. (4) Adverse determination--A determination by a utilization review agent that the health care furnished or proposed to be furnished to an injured employee is not reasonable and necessary.
5. (5) Appeal process--The processes outlined in the Texas Workers' Compensation Act, including but not limited to Texas Labor Code §413.031, Chapter 134, Subchapter G of this title (relating Prospective and Concurrent Review of Health Care), and Chapter 133, Subchapter D of this title (relating to Dispute and Audit of Bills by Insurance Carriers).
6. (6) Certificate--A certificate of registration granted by the commissioner to a utilization review agent.
7. (7) Commissioner--The Commissioner of Insurance.
8. (8) Compensable injury--An injury that arises out of and in the course and scope of employment for which compensation is payable under the Texas Workers' Compensation Act.
9. (9) Complaint--An oral or written expression of dissatisfaction with a utilization review agent concerning the utilization review agent's process. A complaint is not an expression of dissatisfaction with a specific adverse determination, a misunderstanding or misinformation that is resolved promptly by supplying the appropriate information or clearing up the misunderstanding to the satisfaction of the complaining party.
10. (10) Department--Texas Department of Insurance.
11. (11) Dentist--A licensed doctor of dentistry, holding either a D.D.S. or a D.M.D. degree.
12. (12) Doctor--A doctor of medicine, osteopathic medicine, optometry, dentistry, podiatry, or chiropractic who is licensed and authorized to practice.

13. (13) Health care--Includes all reasonable and necessary medical aid, medical examinations, medical treatments, medical diagnoses, medical evaluations, and medical services. The term does not include vocational rehabilitation. The term includes:

    1. (A) medical, surgical, chiropractic, podiatric, optometric, dental, nursing, and physical therapy services provided by or at the direction of a doctor;
    2. (B) physical rehabilitation services performed by a licensed occupational therapist provided by or at the direction of a doctor;
    3. (C) psychological services prescribed by a doctor;
    4. (D) the services of a hospital or other health care facility;
    5. (E) a prescription drug, medicine, or other remedy; and
    6. (F) a medical or surgical supply, appliance, brace, artificial member, or prosthesis, including training in the use of the appliance, brace, member, or prosthesis.
14. (14) Health care facility--A hospital, emergency clinic, outpatient clinic, or other facility providing health care.
15. (15) Health care provider--Any person, corporation, facility, or institution licensed by a state to provide or otherwise lawfully providing health care that is eligible for independent reimbursement for those services.
16. (16) Injured employee--An employee with a compensable injury under the Texas Workers' Compensation Act.
17. (17) Inquiry--A request for information or assistance from a utilization review agent.

18. (18) Insurance carrier---

    1. (A) an insurance company;
    2. (B) a certified self-insurer for workers' compensation insurance; or
    3. (C) a governmental entity that self-insures, either individually or collectively.
19. (19) Insurance company--A person authorized and admitted by the Texas Department of Insurance to do insurance business in this state under a certificate of authority that includes authorization to write workers' compensation insurance.
20. (20) Life-threatening--A disease or condition resulting from a compensable injury, for which the likelihood of death is probable unless the course of the disease or condition is interrupted.

21. (21) Medical benefit--Payment for health care reasonably required by the nature of a compensable injury and intended to:

    1. (A) cure or relieve the effects naturally resulting from the compensable injury, including reasonable expenses incurred by the injured employee for necessary treatment to cure and relieve the injured employee from the effects of an occupational disease before and after the injured employee knew or should have known the nature of the disability and its relationship to the employment;
    2. (B) promote recovery; or
    3. (C) enhance the ability of the injured employee to return to or retain employment.
22. (22) Medical records--The entire history of diagnosis and treatment for a compensable injury, including but not limited to medical, dental, and other health care records from all disciplines rendering care to an injured employee.
23. (23) Nurse--A professional or registered nurse, a licensed vocational nurse, or a licensed practical nurse.
24. (24) Open records law--Government Code Chapter 552.
25. (25) Person--An individual, a corporation, a partnership, an association, a joint stock company, a trust, an unincorporated organization, any similar entity or any combination of the foregoing acting in concert.
26. (26) Physician--A licensed doctor of medicine or a doctor of osteopathy.
27. (27) Preauthorization--The process requesting approval to provide a specific treatment or service prior to rendering the treatment or service as defined and delineated in Chapter 134, Subchapter G of this title (relating to Prospective and Concurrent Review of Health Care).
28. (28) Retrospective review--The process of reviewing health care which has been provided to injured employees under the Texas Workers' Compensation Act to determine if the health care was medically reasonable and necessary.
29. (29) Screening criteria--The written policies, decision rules, medical protocols, TWCC fee and treatment guidelines, and TWCC rules and advisories used by the utilization review agent as part of the utilization review process (e.g., appropriateness evaluation protocol (AEP), and intensity of service, severity of illness, discharge, and appropriateness screens (ISD-A)). The TWCC Treatment Guidelines are tools that identify recommended treatment parameters and typical courses of intervention, whose purpose is to clarify those services that are reasonable and medically necessary. The guidelines are not to be used as fixed treatment protocols by either the health care provider or insurance carrier and shall not be viewed as prescriptive or the sole basis for approval or denial of proposed services. There may be injured employees who will require more or less treatment than is recommended in the guidelines. Treatment falling outside the parameters of the guidelines will be subject to more careful scrutiny and may require additional documentation of special circumstances to justify the need for treatment. Each guideline includes specific ground rules which establish the use of the guideline.
30. (30) Texas Workers' Compensation Act--Texas Labor Code Title 5.
31. (31) Treating doctor--The doctor primarily responsible for treating the injured employee's compensable injury as defined in the Texas Labor Code, §401.011(42).
32. (32) TWCC--Texas Workers' Compensation Commission.
33. (33) Utilization review--A system for preauthorization and concurrent review, or both preauthorization and retrospective review or both concurrent and retrospective review, to determine if health care proposed to be provided, being provided, or which has been provided to an injured employee is medically reasonable and necessary. Utilization review shall not include elective requests for clarification of coverage or prepayment guarantee.
34. (34) Utilization review agent--An insurance carrier, the carriers' agent(s), and/or any entity contracted or subcontracted to provide utilization review.
35. (35) Utilization review plan--The screening criteria and utilization review procedures of a utilization review agent.
36. (36) Working day--A weekday, excluding a legal holiday.

37. (37) Workers' compensation insurance coverage:

    1. (A) an approved insurance policy, pursuant to Article 5.56 of the Insurance Code, to secure the payment of compensation under the Texas Workers' Compensation Act;
    2. (B) coverage to secure the payment of compensation through self-insurance as provided by the Texas Workers' Compensation Act; or
    3. (C) coverage provided by a governmental entity to secure the payment of compensation under the Texas Workers' Compensation Act.
38. (38) Concurrent review--A review of on-going health care for an extension of treatment beyond previously approved health care in accordance with §134.600 of this title (relating to Preauthorization, Concurrent Review, and Voluntary Certification of Health Care).

Source Note:The provisions of this §19.2003 adopted to be effective September 20, 1998, 23 TexReg 9560; amended to be effective June 1, 2003, 28 TexReg 3965.