1. (a) A health care provider may designate one or more individuals as the initial contact or contacts for utilization review agents seeking routine information or data. In no event shall the designation of such an individual or individuals preclude a utilization review agent 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 utilization review agent.
2. (b) Unless precluded or modified by contract, the workers' compensation insurance carrier shall reimburse health care providers for the reasonable costs of providing written medical information, including copying and transmitting any requested injured employee records or other documents pursuant to Chapter 133, Subchapter B of this title (relating to Required Reports). A health care provider's charge for providing medical information to a utilization review agent shall not exceed the cost of copying records set by rules of the Texas Workers' Compensation Commission and may not include any costs that are otherwise specified in TWCC rules and/or guidelines as not reimbursed separately or are recouped as a part of the charge for health care.

3. (c) When conducting utilization review the utilization review agent shall require only the information necessary to complete the review. This information may include identifying information about the injured employee, the treating health care provider, and facilities rendering care. It may also include clinical information regarding the diagnoses of the injured employee and the medical history of the injured employee relevant to the diagnoses and the compensable injury, the injured employee's prognosis, and the treatment plan prescribed by the treating health care provider along with the provider's justification for the treatment plan. It must include the medical information to substantiate the medical necessity for the specific treatment in review. These items shall only be requested when relevant to the utilization review in question, and be requested as appropriate from the health care provider or health care facility. The required information should be obtained from the appropriate source since no one source will have all of this information.

   1. (1) Utilization review agents shall not routinely require hospitals and doctors to supply numerically codified diagnoses or procedures. Utilization review agents may ask for such coding, since if it is known, its inclusion in the data collected increases the effectiveness of the communication.
   2. (2) Utilization review agents shall not routinely request copies of medical records on all injured employees reviewed. During utilization review, copies of medical records should only be required when a difficulty develops in determining whether the health care is medically reasonable and necessary. In those cases, only the necessary or pertinent sections of the record should be required.

4. (d) Information in addition to that described in this section may be requested by the utilization review agent or voluntarily submitted by the health care provider when there is significant lack of agreement between the utilization review agent and health care provider regarding the appropriateness of health care during the review process. "Significant lack of agreement" means that the utilization review agent:

   1. (1) has tentatively determined, through its professional staff, that a service cannot be authorized to be provided or reimbursed;
   2. (2) has referred the case to an appropriate doctor or other health care provider for review; and
   3. (3) has talked to or attempted to talk to the health care provider for further information.
5. (e) The utilization review agent shall share all pertinent clinical and demographic information on individual injured employees among its various divisions (e.g., preauthorization, return to work planning, case management) to avoid duplicate requests for information from injured employees or health care providers.
6. (f) Notwithstanding any other provision of this subchapter, a utilization review agent may not require as a condition of treatment approval, or for any other reason, the observation of a psychotherapy session or the submission or review of a mental health therapist's process or progress notes. This does not preclude the utilization review agent from requiring submission of an injured employee's medical record.

Source Note:The provisions of this §19.2008 adopted to be effective September 20, 1998, 23 TexReg 9560.