Pursuant to 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, IRO review and assignment functions have been consolidated within the HWCN Division of TDI. Previously, IRO assignments related to the medical dispute resolution process for medical necessity were handled by the DWC. These IRO assignments will transfer from the DWC to the HWCN Division effective January 15, 2007. Section 133.308(a), related to medical dispute resolution (MDR) by IROs, provides that all IROs performing review of health care under the Labor Code and Insurance Code, regardless of where the independent review activities are located, shall comply with §133.308. The new rules may be accessed on the TDI-DWC website at: http://www.tdi.state.tx.us/wc/rules/tableofcontents/rulesoptions.html.
NEW FORMS AND CHANGES TO THE PROCESS FOR SUBMITTING NOTICES OF IRO DECISIONS TO TDI.
The HWCN Division has created standardized forms for use by IROs for the notification of and the reporting of the IRO decision as required by the new rules:
- IRO Notice of Decision Templates - These forms are used to notify all parties entitled to receive notice of the decision. They are designed to: (1) provide the IRO review assignment identification; (2) summarize the outcome of the IRO decision and (3) set forth certain required elements, certifications, and personal information of the enrollee/injured employee that identifies the enrollee/injured employee. In an IRO decision issued in relation to a WC non-network retrospective adverse determination, the summarization of the outcome of the IRO decision must include the identification of the prevailing party as determined by the IRO.
- IRO Reviewer Report Templates - These forms contain the information related specifically to the reviewer's comments and are identified by the IRO review assignment ID. To the extent possible, IROs should instruct their reviewers to avoid the inclusion of any identifying personal information of the enrollee/injured employee that could disclose the identity of the enrollee/injured employee because this report is posted on the TDI website.
The IRO Notice of Decision and the IRO Reviewer Report templates are available on the TDI website at: http://www.tdi.state.tx.us/company/indexiro.html. IROs are to provide notice to the HWCN Division of the IRO Notice of Decision at the following electronic mail to: IRODecisions@tdi.state.tx.us.
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 HWCN Division at: 512-322-4216.
Margaret Lazaretti, Deputy Commissioner
Health and WC Network Certification & QA Division
Life, Health & Licensing Program