1. (a) Health care providers shall provide reasonable and necessary health care that:

   1. (1) cures or relieves the effects naturally resulting from the compensable injury;
   2. (2) promotes recovery; and/or
   3. (3) enhances the ability of the employee to return to or retain employment.

2. (b) In addition to the general requirements of this section, health care providers shall timely and appropriately comply with all applicable requirements under the statutes and rules, including, but not limited to:

   1. (1) reporting required information;
   2. (2) disclosing financial interests;
   3. (3) impartially evaluating an employee's condition; and
   4. (4) correctly billing for health care provided.

3. (c) The treating doctor is the doctor primarily responsible for the efficient management of health care and for coordinating the health care for an injured employee's (employee) compensable injury. The treating doctor shall:

   1. (1) except in the case of an emergency, approve or recommend all health care rendered to the employee including, but not limited to, medically reasonable and necessary treatment or evaluation provided through referrals to consulting and referral doctors or other health care providers, as defined in this section;
   2. (2) maintain efficient utilization of health care;
   3. (3) communicate with the employee, employee's representative, if any, employer, and insurance carrier (carrier) about the employee's ability to work or any work restrictions on the employee;

   4. (4) make available, upon request, in the form and manner prescribed by the Division:

      1. (A) work release data;
      2. (B) cost and utilization data;
      3. (C) patient satisfaction data, including comorbidity, "Short Form 12" outcome information (sf 12), and recovery expectations.

4. (d) The consulting doctor is a doctor who examines an employee or the employee's medical record in response to a request from the treating doctor, the designated doctor, or the Division. The consulting doctor shall:

   1. (1) perform unbiased evaluations of the employee as directed by the requestor including, but not limited to, evaluations of:

      1. (A) the accuracy of the diagnosis and appropriateness of the treatment of the injured employee;
      2. (B) the employee's work status, ability to work, and work restrictions;
      3. (C) the employee's medical condition; and
      4. (D) other similar issues;
   2. (2) submit a narrative report to the treating doctor, the employee, the employee's representative (if any), the carrier, and the Division (if the requestor was the Division);
   3. (3) not make referrals without the approval of the treating doctor and when such approval is obtained, ensure that the provider to whom the consulting doctor is making an approved referral knows the identity and contact information of the treating doctor;
   4. (4) initiate or provide treatment only if the treating doctor approves or recommends the treatment; and
   5. (5) become a referral doctor if the doctor begins to prescribe or provide health care to an employee.

5. (e) The referral doctor is a doctor who examines and treats an employee in response to a request from the treating doctor. The referral doctor shall:

   1. (1) supplement the treating doctor's care;
   2. (2) report the employee's status to the treating doctor and the carrier at least every 30 days; and
   3. (3) not make referrals without the approval of the treating doctor and when such approval is obtained, ensure that the provider to whom the referral doctor is making an approved referral knows the identity and contact information of the treating doctor.

6. (f) The Required Medical Examination (RME) doctor is a doctor who examines the employee's medical condition in response to a request from the carrier or the Division pursuant to Labor Code §§408.004, 408.0041, or 408.151. The RME doctor shall:

   1. (1) perform unbiased evaluations of the employee as directed by the RME notice issued by the Division;
   2. (2) not make referrals without the approval of the treating doctor and when such approval is obtained, ensure that the provider to whom the RME doctor is making an approved referral knows the identity and contact information of the treating doctor;
   3. (3) initiate or provide treatment only if the treating doctor approves or recommends the treatment; and

   4. (4) not evaluate, except following an examination by a designated doctor:

      1. (A) the impairment caused by the employee's compensable injury;
      2. (B) the attainment of maximum medical improvement;
      3. (C) the extent of the employee's compensable injury;
      4. (D) whether the employee's disability is a direct result of the work related injury;
      5. (E) the ability of the employee to return to work; or
      6. (F) similar issues.

7. (g) A peer reviewer is a health care provider who, at the insurance carrier's request, performs an administrative a review of the health care of a workers' compensation claim. The peer reviewer must not have any known conflicts of interest with the injured employee or the health care provider who rendered any health care being reviewed.

   1. (1) A peer reviewer who performs a prospective, concurrent, or retrospective review of the medical necessity or reasonableness of health care services (utilization review) is subject to the requirements of Insurance Code Article 21.58A and Chapter 1305 and applicable provisions of the Labor Code. A peer reviewer who performs utilization review must be:

      1. (A) certified or registered as a utilization review agent (URA) by the Texas Department of Insurance or be employed by or under contract with a certified or registered URA to perform utilization review; and
      2. (B) licensed to practice in Texas or perform utilization reviews under the direction of a doctor licensed to practice in Texas.
   2. (2) A peer reviewer who performs a review for any issue other than medical necessity, such as compensability or an injured employee's ability to return to work, must hold an appropriate professional license in Texas.
8. (h) The designated doctor is a doctor assigned by the Division to recommend a resolution of a dispute as to the medical condition of an employee. The qualifications and responsibilities of a designated doctor are governed by §180.21 of this title (relating to Division Designated Doctor List) and other rules providing for use of a designated doctor.
9. (i) A member of the Medical Quality Review Panel (MQRP) is a health care provider chosen by the Division's Medical Advisor under Texas Labor Code §413.0512. All eligibilities, terms, responsibilities, and prohibitions shall be prescribed by contract, and the MQRP members shall serve on the MQRP as prescribed by contract. A provider must meet the performance standards specified in the contract to be eligible for selection by the Medical Advisor to serve on the MQRP. Doctors seeking membership on the MQRP are required to be on the Division's Approved Doctor List.

Source Note:The provisions of this §180.22 adopted to be effective March 14, 2002, 27 TexReg 1817; amended to be effective August 16, 2006, 31 TexReg 6370.