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 Statute 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, 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 commission:

      1. (A) work release data;
      2. (B) cost and utilization data;
      3. (C) patient satisfaction data, including comorbidity, "Short Form 12" outcome information (also known as "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 commission. 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 the narrative report required by §133.104 of this title (relating to Consultant Medical Reports) to the treating doctor, the employee, the employee's representative (if any), the carrier and, the commission (if the requestor was the commission);
   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; and
   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 commission under Texas Labor Code §408.004. The RME doctor shall:

   1. (1) perform unbiased evaluations of the employee as directed by the RME order 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) 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 the employee's maximum medical improvement (MMI) status or permanent whole body impairment except following an examination by a designated doctor or otherwise directed by the commission and when performing such an examination, shall do so in an unbiased manner.

7. (g) The peer or utilization reviewer evaluates medical and health care services, including evaluation of the qualifications of professional health care practitioners and of health care provided by those practitioners. Peer or utilization reviews generally include the evaluation of the:

   1. (1) accuracy of a diagnosis;
   2. (2) quality of the care provided by a health care practitioner; and/or
   3. (3) the reasonableness and medical necessity of health care provided or proposed to be provided to an employee.
8. (h) The designated doctor is a doctor appointed by the commission 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 Commission 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 provider chosen by the commission'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 who seek membership on the MQRP are required to be on the ADL.

Source Note:The provisions of this §180.22 adopted to be effective March 14, 2002, 27 TexReg 1817.