1. (a) Summary report to TDI. By March 1 of each year, each URA certified or registered under this subchapter must submit to TDI through TDI's Internet website a complete summary report of information related to complaints, adverse determinations, and appeals of adverse determinations.

2. (b) Contents of summary report. The summary report required by this section must cover reviews performed by the URA during the preceding calendar year and must include:

   1. (1) the total number of written notices of adverse determinations;
   2. (2) a listing of adverse determinations for preauthorization, by the medical condition and treatment using the physical diagnosis or DSM-IV (mental health diagnosis) coding that is in effect at the time, or successor codes and modifiers, and CPT (procedure) code or other relevant procedure code if a CPT designation is not available, or any other nationally recognized numerically codified diagnosis or procedure;
   3. (3) the classification of the party requesting review, for example, a health care provider; injured employee; or their representative;
   4. (4) the disposition of the appeal of adverse determination (either in favor of the appellant, or in favor of the original utilization review determination) at each level within the internal utilization review process; and
   5. (5) the subject matter of any complaint filed with the URA.

3. (c) Complaints included in summary report. Complaints listed in the summary report under subsection (b)(5) of this section must be categorized as follows:

   1. (1) administration, for example, copies of medical records not paid for, too many calls or written requests for information from provider, and too much information requested from provider;
   2. (2) qualifications of URA's personnel; or
   3. (3) appeal or complaint process, for example, a treating physician unable to discuss the plan of treatment with a utilization review physician; no notice of adverse determination; no notice of clinical basis for adverse determination; or written procedures for appeal not provided.
4. (d) Complaints to TDI. Complaints received by TDI against a URA must be processed under TDI's established procedures for investigation and resolution of complaints.
5. (e) TDI inquiries. TDI may address inquiries to a URA related to any matter connected with URA transactions TDI considers necessary for the public good or for the proper discharge of TDI's duties. Under Insurance Code §38.001, a URA that receives an inquiry from TDI must respond to the inquiry in writing not later than the 10th calendar day after the date the inquiry is received.
6. (f) TDI-DWC inquiries. This section does not limit the ability of the commissioner of workers' compensation or TDI-DWC to make inquiries, conduct audits, or receive and investigate complaints against URAs or personnel employed by or under contract with URAs to perform utilization review to determine compliance with or violations of Labor Code Title 5, Insurance Code, or applicable TDI-DWC rules.

7. (g) On-site review by TDI. For scheduled and unscheduled on-site reviews, TDI may make a complete on-site review of the operations of each URA at the principal place of business for each agent as often as is deemed necessary. An on-site review will only be conducted during working days and normal business hours. A URA must make available all records relating to its operation during any scheduled or unscheduled on-site reviews.

   1. (1) Scheduled on-site reviews. A URA will be notified of any scheduled on-site review by letter, which will specify, at a minimum, the identity of TDI's designated representative and the expected arrival date and time.
   2. (2) Unscheduled on-site reviews. At a minimum, notice of an on-site review of a URA will be in writing and be presented by TDI's designated representative on arrival.

Source Note:The provisions of this §19.2014 adopted to be effective February 20, 2013, 38 TexReg 892.