The utilization review plan shall be reviewed by a physician and conducted in accordance with standards developed with input from appropriate health care providers, including doctors engaged in an active practice that are both primary and specialty doctors, and approved by a physician. The utilization review plan shall include the following components:

1. (1) a description of the elements of review which the utilization review agent provides, including:

   1. (A) prospective and concurrent review in accordance with Chapter 134, Subchapter G of this title (relating to Prospective and Concurrent Review of Health Care);
   2. (B) the elements of review in the TWCC guidelines contained in Chapter 134, Subchapter G of this title (relating to Prospective and Concurrent Review of Health Care);
   3. (C) The elements of review contained in Chapter 133, Subchapter D of this title (relating to Dispute and Audit of Bills by Insurance Carriers).

2. (2) written procedures for:

   1. (A) identification of individuals with special circumstances who may require flexibility in the application of screening criteria through utilization review decisions. Special circumstances include, but are not limited to, a person who has a disability, an acute condition or life-threatening illness. Disability shall not be construed to mean an injured employee who is off work or receiving income benefits;
   2. (B) notification of the utilization review agent's determinations provided in accordance with Chapter 134, Subchapter G of this title and as addressed in §19.2010(b) of this title (relating to Notice of Determinations Made by Utilization Review Agents, Excluding Retrospective Review);
   3. (C) informing appropriate parties of the process for appeal of an adverse determination to TWCC, as required by §19.2011 and §19.2012 of this title (relating to Requirements Prior to Adverse Determination and Appeal of Adverse Determinations of Utilization Review Agents);
   4. (D) receiving or redirecting a toll-free normal business hour and after-hour calls, either in person or by recording, and assurance that a toll-free number will be maintained 40 hours per week during normal business hours as addressed in §19.2013 of this title (relating to Utilization Review Agent's Telephone Access);

   5. (E) review including:

      1. (i) any form used during the review process;
      2. (ii) time frames that shall be met during the review;
   6. (F) handling of oral or written complaints by injured employees, their representatives or health care providers as addressed in §19.2016(a) of this title (relating to Complaints and Reporting Requirements);
   7. (G) determining if doctors or other health care providers utilized by the utilization review agent are licensed, qualified and appropriately trained, including written procedures for ensuring that doctors that perform utilization review for the utilization review agent are either on TWCC's list of approved doctors or, if licensed in another state, will perform utilization review under the direction of a doctor licensed in Texas who is on TWCC's list of approved doctors, in accordance with Chapter 180 of this title (relating to Monitoring and Enforcement);

   8. (H) assuring that injured employee-specific information obtained during the process of utilization review, as addressed in §19.2014 of this title (relating to Confidentiality), will be:

      1. (i) kept confidential in accordance with applicable federal and state laws;
      2. (ii) used solely for the purposes of utilization review, quality assurance and case management;
      3. (iii) shared with only those agencies who have authority to receive such information; and
      4. (iv) in the case of summary data, not considered confidential if it does not provide sufficient information to allow identification of individual injured employees;
   9. (I) providing prior written notice to a doctor or health care provider when publishing data, including quality review studies or performance tracking data which identifies a particular doctor, or health care provider;
3. (3) screening criteria. Each utilization review agent shall utilize written medically acceptable screening criteria as defined in §19.2003 of this title (relating to Definitions) and review procedures which are established and periodically evaluated and updated, at a minimum, upon certification renewal with appropriate involvement from the doctors, including doctors engaged in an active practice, and other health care providers. Utilization review decisions shall be made in accordance with currently accepted medical or health care practices, taking into account special circumstances of each case that may require deviation from the norm stated in the screening criteria. Screening criteria must be objective, clinically valid, compatible with established principles of health care, and flexible enough to allow deviations from the norm when justified on a case-by-case basis. Screening criteria must be used to determine only whether to approve the requested treatment. Denials must be referred to an appropriate doctor or other health care provider to determine whether health care is medically reasonable and necessary. Such written screening criteria and review procedures shall be available for review and inspection to determine appropriateness and compliance as deemed necessary by the commissioner, his or her designated representative, or TWCC and copying as necessary for the commissioner and/or TWCC to carry out the lawful duties under the Insurance Code, and the Texas Labor Code, provided, however, that any information obtained or acquired under the authority of this subchapter and the Act, is confidential and privileged and not subject to the open records law or subpoena except to the extent necessary for the commissioner to enforce this subchapter and the Act, and for TWCC to enforce the Texas Workers' Compensation Act.
4. (4) delegation of review. Provide circumstances, if any, under which the utilization review agent may delegate the review to qualified personnel in the hospital or health care facility where the health care is to be provided. Such delegation shall not relieve the utilization review agent of full responsibility for compliance with this subchapter, the Act, and the Texas Workers' Compensation Act, including the conduct of those to whom utilization review has been delegated.

Source Note:The provisions of this §19.2005 adopted to be effective September 20, 1998, 23 TexReg 9560; amended to be effective June 1, 2003, 28 TexReg 3965.