The purpose of this bulletin is to provide information to utilization review agents (URAs) who intend to perform utilization review for workers' compensation health care networks (WCNs).
HB 7, which was enacted by the 79th Texas Legislature, authorizes the establishment of WCNs. HB 7 provisions related to WCNs are codified in Insurance Code Chapter 1305. Chapter 1305, Subchapter H, contains requirements related to utilization review and retrospective review and provides that the requirements of Insurance Code Article 21.58A also apply to WCNs. The Texas Department of Insurance (TDI) has adopted rules regulating WCNs, including requirements related to utilization review, which may be found at 28 Texas Administrative Code Chapter 10. The rules may be accessed on the TDI website at http://www.tdi.state.tx.us/rules/1115a-059.html.
TDI has received inquiries from URAs, carriers and other interested parties regarding requirements for performing utilization review for WCNs. Based upon the requirements of Chapter 1305, TDI has determined that URAs who perform utilization review for WCNs will need to demonstrate their ability to comply with Chapter 1305. Pursuant to Article 21.58A, § 3(g), which states that URAs are to report any material changes in the information in a certification or renewal form, URAs can update their applications by submitting policies and procedures that relate to WCNs. Such updates will allow URAs to comply with the requirements of Chapter 1305 and are consistent with Article 21.58A. The utilization review requirements that relate to WCNs are located on pages 5-12 of the revised URA application form. The revised application form, (LHL005 Rev. 01/06) which includes instructions to URAs, a URA Application Exhibit Guide and the exhibit checklist, is accessible on the TDI website at: http://www.tdi.state.tx.us/company/indexura.html.
Please note that a fee is not required to update your current URA certification application as described above.
Questions regarding this bulletin should be submitted in writing to the following TDI electronic mailbox: WCNet@tdi.state.tx.us . You may also contact Health and WC Network Certification & QA at: 512-322-4266.
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Margaret Lazaretti, Deputy Commissioner
Health and WC Network Certification & QA
Life, Health & Licensing Program