FIN306
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Officers and Directors Page Complete Listing of all Current Officers and Directors
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PDF |
English |
LHL005
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URA Application Form Application to apply for URA Certification, renew a URA Certification or update a URA Certification.
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PDF |
English |
LHL006
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IRO Application Application to apply for IRO Certification, renew an IRO Certification or update an IRO Certification
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PDF |
English |
LHL007
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Supplemental Certification for IRO Renewal Attach this form to the renewal application. You can attach it in the online renewal form or with the IRO Application, Form LHL006.
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PDF |
English |
LHL009
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Request for Review by an IRO Form used by Patients/Injured Employees or persons acting on their behalf or health care providers to request a review by an Independent Review Organization (IRO) for disputes of medical necessity
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PDF |
English |
LHL009 Spanish
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Solicitud para una revisión por parte de una Organización de Revisión Independiente [En Español] - Solicitud para pedir una revisión por parte de una Organización de Revisión Independiente (Independent Review Organization- IRO por su nombre y siglas en inglés) para las disputas médicas necesarias de pacientes, empleados lesionados, representantes del paciente o proveedores de atención médica.
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PDF |
Spanish |
LHL011
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Notice of Rescission of Preauthorization Exemption and Right to Request an Independent Review
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PDF |
English |
LHL234
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Application Package
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PDF |
English |
LHL234a
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Other Professional Degrees Attachment A
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PDF |
English |
LHL234b
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Other Post-Graduate Education Attachment B
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PDF |
English |
LHL234c
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Other Work History Attachment C
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PDF |
English |
LHL234d
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Other Current Hospital Affiliations Attachment D
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PDF |
English |
LHL234e
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Other Previous Hospital Affiliations Attachment E
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PDF |
English |
LHL234f
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Other Practice Locations Attachment F
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PDF |
English |
LHL234g
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Malpractice Claims History Attachment G
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PDF |
English |
LHL658
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Application for Approval Exclusive Provider Benefit Plan (EPO) and Preferred Provider Benefit Plan (PPO)
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PDF |
English |
LHL705
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Workers’ Compensation Health Care Network Application
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PDF |
English |
LHL706
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Preferred Provider Benefit Plan (PPBP) and Exclusive Provider Benefit Plan (EPBP), Annual Report, Waiver Request, and Access Plan Checklist
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PDF |
English |
LHL707
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HMO Network Access Plan Requirements
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PDF |
English |
LHL708
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Workers' Compensation Network Access Plan Checklist WC Network Access Plan Checklist
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PDF |
English |
LHL709
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Certification of Independence and Qualifications of the Reviewer
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PDF |
English |
LHL710
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Holder of Bonds or Notes Over $100,000
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PDF |
English |
LHL711
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Addendum to Biographical Affidavit
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PDF |
English |
LHL712
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IRO Notice of Decision Template - HC
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WORD |
English |
LHL713
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IRO Notice of Decision Template - WC
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WORD |
English |
LHL715
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Provider Network Contracting Entity Registration and Exemption of Affiliates Form PNCE Registration and Exemption Form
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PDF |
English |
LHL716
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Health Maintenance Organization Annual Network Adequacy Report and Access Plan Checklist
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PDF |
English |
LHL717
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Utilization Review Agent's (URA) Designated Contact for IRO Requests
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PDF |
English |
LHL718
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Health Maintenance Organization (HMO) Physician / Provider Contract Requirements Used as guide to indicate the mandatory provisions and benefits required in a Provider Contract
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PDF |
English |
LHL719
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HMO Delegation Agreement Checklist
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PDF |
English |
LHL720
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Workers' Compensation Health Care Network Provider Contract Checklist
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PDF |
English |
LHL721
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Workers’ Compensation Network Contract with Insurance Carrier Contract Requirements Checklist
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PDF |
English |
LHL722
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Workers' Compensation Health Care Network Management Contract Checklist
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PDF |
English |
NOFR001
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Prior Authorization of Health Care Services
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PDF |
English |
NOFR002
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Texas Standard Prior Authorization Request Form for Prescription Drug Benefits
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PDF |
English |
SN002
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Notice to HMO Enrollees: Have a complaint about your HMO?
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PDF |
English |
SN002s
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¿Tiene una queja relacionada con su HMO?
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PDF |
Spanish |
SN003
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Workers Comp Network Sample Contingency Plan
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PDF |
English |
SN004
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Workers Comp Net Sample Employee Acknowledgment Form
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PDF |
English |
SN005
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Workers Comp Net Employee Acknowledgment Form
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PDF |
Spanish |
SN006
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Workers Comp Net Sample Employee Acknowledgment Form - Chinese
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PDF |
Chinese |
SN007
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Workers Comp Net Sample Employee Acknowledgment Form
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PDF |
Vietnamese |
SN008
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Workers Comp Network Sample QI Report
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PDF |
English |
SN009
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Sample URA Adverse Determination Notice, Health
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PDF |
English |
SN010
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Sample URA Adverse Determination Notice, Specialty Health
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PDF |
English |
SN011
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Sample URA Adverse Determination Notice, Workers Comp Net
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PDF |
English |
SN012
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Sample URA Adverse Determination Notice, Workers Comp Non-Network
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PDF |
English |
SN013
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Contract List
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PDF |
English |
SN014
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Delegated Entity Data Form Sample format for use by HMOs and WC HCNs when submitting delegation agreements to the Texas Department of Insurance
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PDF |
English |
SN016
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Sample Network Adequacy Contracted Provider List
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EXCEL |
English |
SN017
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Sample Network Adequacy Access Plan
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EXCEL |
English |