The purpose of this bulletin is to notify the above-listed parties that the United States 5 th Circuit Court of Appeals entered an order on August 30, 2000 which stays its ruling in Corporate Health Insurance, et al. Inc. v . The Texas Department of Insurance, et al. (" Corporate") to provide the Texas Department of Insurance (TDI) with the opportunity to appeal the ruling to the United States Supreme Court. The initial Corporate ruling stated that the Employee Retirement Income Security Act ("ERISA") preempts Texas' Independent Review Organization (IRO) process for independent review. However, because this order has now been stayed , all statutes and regulations related to independent reviews remain in effect and shall continue to be enforced by TDI until the U.S. Supreme Court makes a determination on this matter.
IRO Requests: All insurers, health maintenance organizations, and utilization review agents (URAs) must continue to notify enrollees of their right to seek review from an IRO of an adverse determination, and of the procedures for obtaining that review, pursuant to Texas Insurance Code Article 21.58A §§6 and 6A. All insurers, HMOs, and URAs must continue to submit requests for independent review of an adverse determination to TDI for processing and assignment to an IRO.
URA Filings: All URA applicants for an original certificate or registration or renewal certificate must continue to comply with the requirements of the Texas Insurance Code, Article 21.58A, and TDI rules ( 28 Texas Administrative Code, Chapter 19, Subchapter R). An application for a URA original certificate or registration must, therefore, include policies and procedures related to the IRO process.
HMOs: TDI will continue to require HMOs to comply with the requirements of the Texas Insurance Code, Articles 20A.12A, and 21.58A and TDI rules. HMOs, therefore, must continue to include policies and procedures related to the IRO process in their Evidences of Coverage (EOC) and other enrollee materials.
Insurers: Pursuant to the Texas Insurance Code, Article 21.58A, Section 14(h), insurers who perform their own utilization review must continue to comply with the requirements of the Texas Insurance Code Article 21.58A and TDI rules ( 28 Texas Administrative Code, Chapter 19, Subchapter R).
If you have any questions regarding this bulletin, please contact Blake O. Brodersen, Deputy Commissioner for the HMO Division, or Olga Escobedo, Director of the Compliance/URA/IRO Section, at 512-322-4266.
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Kimberly Stokes
Senior Associate Commissioner
Life, Health & Licensing Program