Senate Bill 386, passed by the 75th Legislature, requires that any utilization review agent, insurance company or HMO performing utilization review notify the patient, a person acting on the patient´s behalf, and the patient´s health care provider of the right to a review by an Independent Review Organization (IRO) of an adverse determination and the procedures for obtaining that review. "Adverse determination" is defined as a determination by a utilization review agent that the health care services furnished or proposed to be furnished to a patient are not medically necessary or not appropriate. The right to request an independent review does not apply to services not covered by the benefit plan.
The purpose of this bulletin is to remind you of your responsibility to notify the above parties who receive an adverse determination of their right to an independent review of that determination by an independent review organization in accordance with Article 21.58A of the Texas Insurance Code.
The notice of an adverse determination by a utilization review agent must include:
- The principal reason for the adverse determination;
- The clinical basis for the adverse determination;
- A description or the source of the screening criteria;
- A description of the procedure for the complaint and appeal process;
- The IRO notification form prescribed by the Texas Department of Insurance and;
- The IRO request form prescribed by the Texas Department of Insurance.
Review by an IRO is available for adverse determinations that have been upheld upon appeal of the utilization review decision. If the adverse determination involves a non-life threatening condition, the patient, a person acting on behalf of the patient and the patient´s health care provider should follow the internal procedure set forth by the utilization review agent for appeals. The appealing party is entitled to request an independent review at any time after the first level appeal.
When an adverse determination is upheld, the utilization review agent must again provide the appealing party written notification of the right to seek review of the denial by an IRO. The notification must include:
- The clinical basis for the appeal´s denial;
- The specialty of the physician making the denial;
- The IRO notification form prescribed by the Texas Department of Insurance and;
- The IRO request form prescribed by the Texas Department of Insurance.
If an adverse determination involves a life-threatening condition, any of the above parties have the right to request immediate assignment of an IRO without filing an appeal. The patient, a person acting on the patient´s behalf, or the patient´s provider, makes the determination as to the existence of a life-threatening condition.
It is important that utilization review agents submit the request for an independent review to the Department immediately upon receipt, since the statute allows the utilization review agent only three business days from time of receipt to provide the IRO with all records and documents necessary to conduct the review. You may obtain the IRO notification and request forms directly from the Texas Department of Insurance, HMO/URA Division, P.O. Box 149104, Austin Texas, 78714-9104. Fax: 512-322-4260
The Department of Insurance requires all entities performing utilization review to provide proper notification to individuals of the right to review by an IRO and timely submission of requests for an independent review to the Department. Please distribute this bulletin to the persons responsible for implementing these notice requirements in your organization.
If you have any questions regarding this bulletin, please contact Karen Thrash, Deputy Commissioner for HMO/URA, at 512-322-4266.
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ELTON BOMER
COMMISSIONER OF INSURANCE