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 certified workers' compensation network health care (WC network) and workers' compensation health care not involving a certified workers compensation network (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.
In conjunction with the consolidation of the DWC and HWCN Division IRO review and assignment functions, there are new forms and processes for all URAs to use when notifying the HWCN Division of a request for review by an IRO, submitted by either an injured employee, a person acting on the injured employee's behalf, or a health care provider.
REQUEST FOR REVIEW AND AVAILABILITY OF FORMS
For WC non-network carriers and URAs, the rules implement two important changes to the initial steps of the IRO request process.
- First, the injured employee, a person acting on the injured employee's behalf, 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 resolution by IROs. The IRO Request form LHL009 and other related forms are available on the TDI-HWCN website at: http://www.tdi.state.tx.us/company/iro_requests.html.
For utilization review performed for a WC network, the carrier or URA currently supplies 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, concurrent or retrospective reviews of medical necessity, and, if applicable, when an adverse determination is issued following a reconsideration review.
When utilization review is performed for WC non-network health care services, the carrier or URA will be required to provide the IRO Request form LHL009 to the injured employee, the injured employee's representative and the health care provider 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, and, if applicable, when an adverse determination is issued following a reconsideration review.
When an adverse determination is issued for preauthorization or on a concurrent basis for either WC network or WC non-network services and an injured employee is considered to have a life-threatening condition as defined by rule, the injured employee, the 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 should continue to submit such claims to DWC to be processed according to applicable DWC requirements.
ONLINE IRO REQUEST FORM
As of January 15, 2007, carriers and URAs will be directed to submit the IRO Request form LHL009 to the HWCN Division through an online form accessible on the Internet website of TDI. On December 11, 2006 the HWCN Division provided carriers, URAs, and Certified Workers' Compensation Health Care Networks with information on how to obtain sign-on access for the online IRO request form LHL009 and instructions on how to use the online IRO request system. The new online IRO Request form LHL009 is available on the TDI-HWCN website at: http://www.tdi.state.tx.us/company/iro_requests.html or if necessary, the form is available in a paper format by submitting the required documentation to the HWCN Division by facsimile sent to: 512-490-1011.
POSTING OF IRO DECISIONS
IRO decisions related to a review of an adverse determination of a WC network or a WC non-network medical necessity dispute that is requested on or after January 15, 2007 will be posted on the TDI-HWCN website at: http://www.tdi.state.tx.us/company/iro_requests.html. IRO decisions related to a review of an adverse determination of a WC non-network medical necessity dispute that was requested prior to January 15, 2007 will be posted on the TDI-DWC website 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 mail to: 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