The purpose of this bulletin is to provide information regarding the Texas independent review organization (IRO) review process to HCPs who provide health care services to Texas enrollees or injured employees of Texas employers who have coverage through:
- Health insurance policies, preferred provider organizations and health maintenance organization plans (health)
- Workers' compensation health care policies not involving a certified workers' compensation network (WC non-network)
- Certified workers' compensation health care networks (WC network)
SINGLE PROCESS PURSUANT TO NEW RULES
New rules, Texas Administrative Code (TAC) Title 28, Chapter 133, Subchapter D (related to Dispute of Medical Bills), §§133.305, 133.307, and 133.308, provide for a single process for the submission and processing of notices and requests for review by an IRO for both WC network and WC non-network within the Health and Workers' Compensation Network Certification and Quality Assurance Division (HWCN Division) of the Texas Department of Insurance (TDI). Therefore, the IRO assignment function for WC non-network medical dispute resolution will transition from the Workers' Compensation Division (DWC) to the HWCN Division effective January 15, 2007. The new rules may be accessed on the TDI-DWC website at: http://www.tdi.state.tx.us/wc/rules/tableofcontents/rulesoptions.html.
The newly created single process for workers' compensation WC network and WC non-network requests for IRO reviews of adverse determinations related to disputes of medical necessity will be incorporated into the HWCN Division's existing assignment process for requests for IRO reviews submitted by utilization review agents (URAs) that perform utilization review for health insurance policies, preferred provider plans, plans provided by health maintenance organizations, and health care services provided through certified workers' compensation networks.
REQUEST FOR REVIEW AND AVAILABILITY OF FORMS
For requests for review by an IRO related to a WC non-network adverse determination, the rules implement two important changes to the initial steps of the IRO request process.
- First, the injured employee, a person acting on behalf of the injured employee, or a health care provider must complete the Request for Review by an IRO form (IRO Request form LHL009). Beginning January 15, 2007, the form previously used, the DWC-60 form, will not be accepted for requests for medical necessity dispute by IROs. The IRO Request form LHL009 and other related forms are available on the TDI website at: http://www.tdi.state.tx.us/company/iro_requests.html. The IRO Request form LHL009 is the same form currently used by carriers and URAs in relation to requests for review by an IRO for health care plan and WC networks.
Health URAs supply the IRO Request form LHL009 to their enrollees or persons acting on behalf of enrollees and to HCPs who requested the health care services at the time a notice of an adverse determination (denial) is issued in relation to preauthorization or concurrent reviews of medical necessity. The IRO Request form LHL009 is provided both at the time of the initial adverse determination and, if applicable, when an adverse determination is issued following an appeal review.
For utilization review performed for a WC network, the carrier or the URA currently supply the IRO Request form LHL009 to the injured employee, the injured employee's representative, and the health care provider at the time a notice of an adverse determination is issued in relation to preauthorization or concurrent or retrospective reviews of medical necessity. The IRO Request form LHL009 is provided both at the time of the initial adverse determination and, if applicable, when an adverse determination is issued following a reconsideration review.
For utilization review performed for WC non-network health care services, the carrier or the URA will be required to provide the IRO Request form LHL009 to the injured employee, the injured employee's representative, and the HCP in the same manner as for an injured employee who receives health care services from a WC network when an adverse determination is issued in relation to preauthorization or concurrent reviews of medical necessity. The IRO Request form LHL009 will be provided both at the time of the initial adverse determination and, if applicable, when an adverse determination is issued following a reconsideration review.
When adverse determinations are issued for preauthorization or on a concurrent basis under a health care plan, a WC network plan, or WC non-network plan, and an enrollee/injured employee is considered to have a life-threatening condition as defined by rule, the enrollee/injured employee, the enrollee's/injured employee's representative, or the health care provider may not be required to complete the reconsideration process before requesting a review by an independent review organization.
- Second, after the IRO Request form LHL009 has been completed, the form will be returned to the carrier or the URA, as appropriate. The carrier or the URA will submit the required notice and supporting documentation to the HWCN Division for review and assignment to a certified IRO. The HWCN Division will then notify all parties involved in the dispute of the IRO assignment. Requests for review related to fee disputes for WC non-network medical claims will not transfer to the HWCN Division. Carriers and URAs will continue to submit such claims to DWC to be processed according to applicable DWC requirements.
ONLINE IRO REQUEST FORM
On or after January 15, 2007, URAs are required to submit the IRO Request form LHL009 to the HWCN Division through an online form accessible on the TDI website. A password issued by TDI will be required to access the online IRO Request form. Carriers and URAs have been provided with information on how to obtain sign-on access for the online IRO request form and to conduct training on the use of the online IRO request system. If a carrier or URA does not have access to the Internet, then a paper version of the online IRO form can be requested by contacting the HCWN Division.
POSTING OF IRO DECISIONS
IRO decisions related to reviews of adverse determinations of WC network and WC non-network medical necessity disputes received on or after January 15, 2007 will be posted on the TDI website at: http://www.tdi.state.tx.us/company/iro_requests.html. IRO decisions related to reviews of adverse determinations of WC non-network medical necessity disputes received prior to January 15, 2007 will continue to be posted on the TDI and DWC websites at: http://www.tdi.state.tx.us/wc/admindecisions.html#medcases.
Questions regarding this bulletin should be submitted in writing to the following TDI electronic mailto:URAGrp@tdi.state.tx.us. You may also contact the HWCN Division at: 512-322-4266.
Margaret Lazaretti, Deputy Commissioner
Health and WC Network Certification & QA Division
Life, Health & Licensing Program