1. (a) When a retrospective review is performed:

   1. (1) such retrospective review shall be based on written screening criteria as defined in §19.2003 of this title (relating to Definitions) established and periodically updated, at a minimum, upon certification renewal with appropriate involvement from doctors, including doctors engaged in an active practice, and other health care providers; and
   2. (2) such retrospective review shall be under the direction of a physician and performed in accordance with Chapter 133, Subchapter D of this title (relating to Dispute and Audit of Bills by Insurance Carriers).
2. (b) When retrospective review results in an adverse determination or denial of payment, the utilization review agent shall notify the health care providers of the opportunity to appeal the determination through the appeal process as outlined in Chapter 133, Subchapter D of this title (relating to Dispute and Audit of Bills by Insurance Carriers).

Source Note:The provisions of this §19.2015 adopted to be effective September 20, 1998, 23 TexReg 9560; amended to be effective June 1, 2003, 28 TexReg 3965.