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Texas Department of Insurance
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URA Original Application Naming Convention

Application Documents

Documents Naming convention
Exhibit 1: Summary of the Utilization Review Plan 1 UR Plan P&P
Attachment A: General Standards of Utilization Review 1A UR Standards P&P
Attachment B: Mental Health Process and Progress Notes 1B Mental Health P&P  
Attachment C: Notice of Determinations Made in Utilization Review 1C AD P&P
Notice of Adverse Determination Letter 1C AD LTR
Attachment D: Requirements Prior to Issuing Adverse Determination 1D P2P P&P
Attachment E: Independent Review of Adverse Determination 1E IR of AD P&P
Attachment F: Preauthorization for Health Maintenance Organizations and Preferred Provider Benefit Plans 1F Preauth HMO & PPO P&P
Exhibit 2: Categories of Personnel 2 Personnel List
Exhibit 3: Appeal of Adverse Determinations 3 Appeal of AD
Appeal Acknowledgment Letter 3 ACK LTR
One-Page Appeal Form 3 1pg Form
Appeal Determination Letter 3 APPEAL LTR
IF there is separate letter for denial for step therapy; TIC Sec. 1369.0546(f) 3 APL STPTHRPY
IF there is separate letter for denial for drug formulary; TIC Sec. 1369.056 3 APL DRGFORM
IF there is separate letter for denial for Acquired Brain Injury (ABI); TIC Sec. 1352.006 3 APL ABI
Exhibit 4: Telephone Access 4 Phone Access
Exhibit 5: Organization Information 5 Org Info
Franchise Tax Account Status 5 Franchise Tax
TX Secretary of State 5 SOS
Organization Chart 5 ORG Chart
Letter of Good Standing 5 LTR of Good Standing
Exhibit 6: Biographical Information 6 Bio Info
Biographical Affidavit (submit each individual’s bio as a separate file, with the individual’s name). 6 Bio J. Doe
Fingerprints (IdentoGo Receipt) (submit each individual’s fingerprint receipt as a separate file, with the individual’s name). 6 IdentoGo J. Doe
Request for a Review by an Independent Review Organization (IRO) Instructions LHL009|0522 TX IRO Form
Federal External Review Process Form FERP Form
Utilization Review Agent Application LHL005|0923 LHL005
Attestation ATTEST

It is highly recommended to keep file names as short as possible, to avoid issues with character limitations.

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Last updated: 11/10/2023