Questions regarding 28 Texas Administrative Code (TAC) §133.308, MDR of Medical Necessity Disputes
An independent review organization (IRO) is an organization that the Texas Department of Insurance (TDI) certifies under Insurance Code Chapter 4202. An IRO provides an independent review of health care services denied by an insurance carrier’s utilization review agent or certified workers' compensation network on the basis that the services are not medically necessary or appropriate or are experimental or investigational.
Requests for review by an IRO are processed by TDI’s Managed Care Quality Assurance Office (MCQA).
Learn more about the IRO process, including workers’ compensation network claims.
- A health care provider, or pharmacy processing agent acting on behalf of a pharmacy, when a denial (adverse determination) is issued for a preauthorization or concurrent utilization review request, or after retrospective review of a medical bill.
- An injured employee, or person acting on behalf of the employee, when an adverse determination is issued for a preauthorization or concurrent utilization review request, or when the injured employee paid for medical services and requested reimbursement from the insurance carrier.
- A subclaimant for a retrospective medical necessity dispute in accordance with 28 TAC §§140.6, 140.7, and 140.8 as applicable.
The following two conditions must be met before a request for review by an IRO is submitted:
- The insurance carrier or the insurance carrier’s utilization review agent (URA) issues an adverse determination for a medical bill, or a request for preauthorization or concurrent utilization review, and
- an adverse determination is issued for a request for reconsideration (appeal).
Note: An employee with a life-threatening condition is entitled to an immediate IRO review and is not required to request reconsideration.
The Request for Review by an IRO (LHL009) must be submitted to the insurance carrier or the insurance carrier's URA that issued the adverse determination no later than 45 calendar days after receiving an adverse determination of an appeal.
You can get a copy of the LHL009 online or by calling 866-554-4926.
- The insurance carrier or insurance carrier’s URA sends the request to the MCQA office to assign an IRO.
- MCQA reviews the request, assigns an IRO, and gives the requester and the URA the IRO information.
- The insurance carrier or insurance carrier’s URA sends all medical records listed in 28 TAC §133.308 and any related information to the IRO by the third working day after receiving the notice from MCQA.
If the health care provider or injured employee has records or related information, they may fax or mail them to the IRO using the fax number or address provided on the notification letter.
The IRO may request additional information from either party or from other health care providers whose records are relevant to the review. If the IRO requests records from a health care provider who is not a party to the dispute, the insurance carrier must reimburse the health care provider for the cost of copying those records. Reimbursement for copies of records is established by §134.120 (relating to Reimbursement for Medical Documentation).
The IRO may request that DWC order a designated doctor examination, no later than 10 days after the IRO receives notification of assignment. The insurance carrier will reimburse the designated doctor for the examination.
- No later than eight days after the IRO receives the dispute for a life-threatening condition.
- No later than the 20th day after the IRO receives the dispute for a preauthorization and concurrent medical necessity dispute.
- No later than the 30th day after the IRO receives the IRO fee for a retrospective medical necessity dispute.
When a designated doctor examination is requested, the above time frames begin on the date the IRO receives the designated doctor report.
The IRO sends the decision and relevant documentation to the requester, insurance carrier, and URA. The IRO also sends a copy of the decision to MCQA that includes a certification of the date the decision was sent, and how it was sent (i.e., U.S. mail, delivery service).
Note: If the IRO determines that the health care previously denied by the insurance carrier using a peer review report is medically necessary, the insurance carrier may not use the peer review report for future medical necessity denials of the same health care services for same compensable injury.
- The injured employee is not required to pay for any part of an IRO review.
- For preauthorization, concurrent review, or employee reimbursement disputes, the insurance carrier pays the assigned IRO within 15 days after receiving the invoice from the IRO.
- For retrospective medical necessity disputes, the requester pays the assigned IRO within 15 days after receiving the invoice from the IRO.
- If the IRO fee has not been received within 15 days of the requester’s receipt of the invoice, MCQA t will dismiss the dispute.
- For retrospective medical necessity disputes, the non-prevailing party pays or refunds the IRO fee to the prevailing party not later than 15 days of the IRO decision, even if an appeal of the IRO decision has been or will be filed.
- If a requester withdraws the request after the IRO has been assigned, but before the IRO sends the case to an IRO reviewer, the requester pays the IRO a $150 withdrawal fee within 30 days.
- If a requester withdraws the request after the case is sent to a reviewer, the requester pays the IRO the full review fee within 30 days.
A party to a medical necessity dispute may appeal the IRO decision by submitting a written request to the DWC’s Chief Clerk of Proceedings (Chief Clerk) for a CCH conducted by a DWC administrative law judge.
The written appeal must be filed no later than 20 days after the date the IRO decision is sent to the appealing party.
- Requests that are timely submitted to a local field office will be considered timely filed and will be forwarded to the Chief Clerk for processing.
An IRO decision is not a DWC decision. Neither MCQA nor DWC is considered a party to an appeal.