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Advisory 96-10

TWCC Participation in Hearings Regarding Preauthorization Disputes

House Bill 1089 of the 1995 Texas Legislature transferred jurisdiction over most hearings to resolve medical disputes to the State Office of Administrative Hearings (SOAH) effective January 1, 1996. Procedural changes and other new requirements have increased the amount of time the Commission's legal representatives must devote to each case. Due to budgetary constraints, the Commission has determined that its available resources would be utilized best in cases where the Commission's participation would be most beneficial.

Commission participation often is limited in hearings regarding preauthorization disputes because those hearings typically involve evaluation of a provider's rationale for recommending treatment compared with the rationale of the carrier's peer reviewer who has recommended against it, and the provider and carrier represent their respective positions sufficiently. Therefore, beginning August 1, 1996, a legal representative of the Commission will not participate in most SOAH hearings in which the only issue is whether a proposed medical service should be preauthorized. In those cases, the legal representative of the Commission will notify the SOAH administrative law judge and the other parties, in writing, that the representative will not attend the hearing. Even though the Commission's legal representative does not attend such a hearing, that representative will file with SOAH and the other parties a copy of the certified record of the Medical Review Division's review of the dispute and a statement of matters asserted as required by the Commission's Rules 148.21 (j) and 148.4 (b).

The Commission's staff will review preauthorization disputes on a case-by-case basis. Based upon that review, a legal representative of the Commission will attend and participate fully in some preauthorization hearings at SOAH, including those which, in the opinion of the staff, involve experimental or controversial services or services which otherwise merit close scrutiny. In addition, the legal representatives of the Commission will continue to attend and participate fully in all SOAH hearings which involve issues other than preauthorization.

Signed June 28, 1996

Todd K. Brown, Executive Director