| 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 |
| Letter from TX Secretary of State |
5 SOS |
| Organization Chart |
5 ORG Chart |
| Letter of Good Standing from TX Comptroller (Franchise Tax) |
5 Franchise Tax |
| 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|0824 |
TX IRO Form |
| Federal External Review Process Form (not applicable to workers' compensation) |
FERP Form |
| Utilization Review Agent Application LHL005|0923 |
LHL005 |
| Attestation |
ATTEST |
