1. (a) Utilization review agent's complaint system. A utilization review agent shall establish and maintain a complaint system that provides reasonable procedures for the resolution of oral or written complaints initiated by injured employees, their representatives, or health care providers, concerning the utilization review process, and shall maintain records of such complaints for three years from the time the complaints are filed. The complaint procedure shall include a written response to the complainant by the agent within 30 days of the agent's receipt of the complaint.

2. (b) Utilization review agent's complaint reporting requirements to the department. By March 1, of each year, the utilization review agent shall submit to the commissioner or his or her delegated representative a summary report of all complaints involving workers' compensation at such times and in such form as the commissioner may require, and shall permit the commissioner to examine the complaints and all relevant documents at any time. To be disclosed in the report is the subject matter of the complaint categorized as follows:

   1. (1) administration (e.g., copies of medical records not paid for, too many calls or written requests for information from provider, too much information requested from provider);
   2. (2) qualifications of utilization review agent's personnel;
   3. (3) complaint process (e.g., treating doctor has not been afforded the opportunity to discuss plan of treatment with utilization review physician, no notice of adverse determination, no notice of clinical basis for adverse determination, written procedures for appeal to TWCC not provided).

3. (c) Utilization review agent's adverse determination reporting requirements to the department. The summary report also covers reviews performed by the utilization review agent during the preceding calendar year and includes:

   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 primary ICD-9 (physical diagnosis) or DSM-IV (mental health diagnosis) code, 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; and
   3. (3) the classification of party requesting review (i.e., health care provider, injured employee, their representative, etc.).

4. (d) Complaints to the department. Within a reasonable time period, upon receipt of a written complaint alleging a violation of this subchapter or the Act, by a utilization review agent, from an injured employee, their representative or health care provider, the commissioner or his or her delegated representative shall investigate the complaint, notify the utilization review agent of the complaint, require response by the utilization review agent addressing the complaint within 10 days of receipt of the complaint, and furnish a written response to the complainant and the utilization review agent named. This response must include the following:

   1. (1) a statement of the original complaint;
   2. (2) a statement of the findings of the commissioner or his or her delegated representative and an explanation of the basis of such findings;
   3. (3) corrective actions, if any, on the part of the utilization review agent which the commissioner or his or her designated representative finds appropriate and whether the utilization review agent has voluntarily agreed to take such action; and
   4. (4) a time frame in which any corrective actions should be completed.
5. (e) Evidence of corrective action. The utilization review agent will provide evidence of corrective action within the specified time frame to the commissioner or his or her representative.
6. (f) Authority of the department to make inquiries. In addition to the authority of the commissioner to respond to complaints described in subsection (b) of this section, the department is authorized to address inquiries to any utilization review agent in relation to the agents' business condition or any matter connected with its transactions which the department may deem necessary for the public good or for a proper discharge of its duties. It shall be the duty of the agent to promptly answer such inquiries in writing.
7. (g) Lists of utilization review agents. The commissioner shall maintain and update monthly a list of utilization review agents issued certificates and the renewal date for those certificates. The commissioner shall provide the list at cost to all individuals or organizations requesting the list.

8. (h) On-site review by the Texas Department of Insurance.

   1. (1) The commissioner or the commissioner's designated representative is authorized to make a complete on-site review of the operations of each utilization review agent at the principal place of business for such agent, as often as is deemed necessary.
   2. (2) Utilization review agents will be notified of the scheduled on-site visit by letter, which will specify, at a minimum, the identity of the commissioner's designated representative and the expected arrival date and time.
   3. (3) The utilization review agent must make available during such on-site visits all records relating to its operation.
   4. (4) The commissioner or the designated representative may perform periodic telephone audits of utilization review agents authorized to conduct business in this state to determine if the agents are reasonably accessible.

Source Note:The provisions of this §19.2016 adopted to be effective September 20, 1998, 23 TexReg 9560.