Section 12.205 - Independent Review Organization Contact with and Receipt of Information from Health Care Providers and Patients(a) A health care provider may designate one or more individuals as the initial contact or contacts for IROs seeking routine information or data. In no event will the designation of an individual or individuals as the initial contact prevent an IRO or medical director from also contacting a health care provider or others in his or her employ where a review might otherwise be unreasonably delayed, or where the designated individual is unable to provide the necessary information or data requested by the IRO.(b) An IRO may not engage in unnecessary or unreasonably repetitive contacts with the health care provider or patient and must base the frequency of contacts or reviews on the severity or complexity of the patient's condition or on necessary treatment and discharge planning activity.(c) In addition to pertinent files containing medical and personal information, the utilization review agent or the health insurance carrier, health maintenance organization, managed care entity, or other payor requesting the independent review is responsible for timely delivering to and ensuring receipt by the IRO of any written narrative supplied by the patient in compliance with Insurance Code Chapter 4201 and Chapters 19 and 133 of this title. However, in instances of a life-threatening condition, the IRO must contact the patient or patient's representative, and provider directly.(d) An IRO must notify the department if, within three working days of receipt of the independent review assignment, the IRO has not received the pertinent files containing medical and personal information from the requesting utilization review agent or the health insurance carrier, health maintenance organization, managed care entity, or other payor.(e) An IRO must reimburse health care providers for the reasonable costs of providing medical information in writing, including copying and transmitting any patient records or other documents requested by the IRO. A health care provider's charge for providing medical information to an IRO must not exceed the cost of copying set by TDI-DWC rules at § 134.120 of this title for records, and may not include any costs that are otherwise recouped as a part of the charge for health care. The utilization review agent, health insurance carrier, health maintenance organization, managed care entity, or other payor requesting the review must pay these unreimbursed costs to the health care provider.(f) Nothing in this section prohibits a patient, the patient's representative, or a provider of record from submitting pertinent records to an IRO conducting independent review.(g) When conducting independent review, the IRO must request and maintain any information necessary to review the adverse determination not already provided by the utilization review agent, health insurance carrier, health maintenance organization, managed care entity, or other payor. This information may include identifying information about the patient, the benefit plan, the treating health care provider, or facilities rendering care. It may also include clinical information regarding the diagnoses of the patient and the medical history of the patient relevant to the diagnoses, the patient's prognosis, or the treatment plan prescribed by the treating health care provider along with the provider's justification for the treatment plan.(h) The IRO is required to share all clinical and demographic information on individual patients among its various divisions to avoid duplication of requests for information from patients or providers.28 Tex. Admin. Code § 12.205
The provisions of this §12.205 adopted to be effective November 26, 1997, 22 TexReg 11363; amended to be effective December 26, 2010, 35 TexReg 11281; Amended by Texas Register, Volume 40, Number 19, May 8, 2015, TexReg 2565, eff. 7/7/2015