AI-assisted research summary: The utilization review agent, insurance carrier, department, and carrier/network have specific duties for independent review of adverse determinations and related disputes.
Sec. 1305.355. INDEPENDENT REVIEW OF ADVERSE DETERMINATION. (a) The utilization review agent shall: (1) permit the employee or person acting on behalf of the employee and the employee's requesting provider whose reconsideration of an adverse determination is denied to seek review of that determination within the period prescribed by Subsection (b) by an independent review organization assigned in accordance with Chapter 4202 and commissioner rules; and (2) provide to the appropriate independent review organization, not later than the third business day after the date the utilization review agent receives notification of the assignment of the request to an independent review organization: (A) any medical records of the employee that are relevant to the review; (B) any documents used by the utilization review agent in making the determination; (C) the response letter described by Section 1305.354(a)(4); (D) any documentation and written information submitted in support of the request for reconsideration; and (E) a list of the providers who provided care to the employee and who may have medical records relevant to the review. (b) A request for independent review under Subsection (a) must be timely filed by the requestor as follows: (1) for a request for preauthorization or concurrent review by an independent review organization, not later than the 45th day after the date of denial of a reconsideration for health care requiring preauthorization or concurrent review; or (2) for a request for retrospective medical necessity review, not later than the 45th day after the denial of reconsideration. (c) The insurance carrier shall pay for the independent review provided under this subchapter. (d) The department shall assign the review request to an independent review organization. An independent review organization that uses doctors to perform reviews of health care services under this chapter may only use doctors licensed to practice in this state. (e) A party to a medical dispute that remains unresolved after a review under this section is entitled to a hearing and judicial review of the decision in accordance with Section 1305.356. The division of workers' compensation and the department are not considered to be parties to the medical dispute. (f) A determination of an independent review organization related to a request for preauthorization or concurrent review is binding during the pendency of a dispute and the carrier and network shall comply with the determination. (g) If a contested case hearing or judicial review is not sought under Section 1305.356, the carrier and network shall comply with the independent review organization's determination. Added by Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 4.02, eff. September 1, 2005. Amended by: Acts 2007, 80th Leg., R.S., Ch. 133 (H.B. 1003), Sec. 3, eff. September 1, 2007. Acts 2007, 80th Leg., R.S., Ch. 730 (H.B. 2636), Sec. 2G.011, eff. April 1, 2009. Acts 2011, 82nd Leg., R.S., Ch. 1162 (H.B. 2605), Sec. 2, eff. September 1, 2011. Acts 2019, 86th Leg., R.S., Ch. 1218 (S.B. 1742), Sec. 3.12, eff. September 1, 2019.