Section 19.1716 - Specialty URA(a) Application. To be certified or registered as a specialty URA, an applicant must submit to TDI the application, information, and fee required in § 19.1704 of this title (relating to Certification or Registration of URAs).(b) Same specialty required. A specialty URA must conduct utilization review under the direction of a health care provider who is of the same specialty as the agent and who is licensed or otherwise authorized to provide the specialty health care service in Texas. To conduct utilization review, a specialty URA must be of the same specialty as the health care provider who ordered the service. For example, when conducting utilization review of prescription drugs prescribed by a physician with a specialty in neurological surgery, the specialty URA must be a physician with a specialty in neurological surgery.(c) Rule requirements. A specialty URA is subject to the requirements of this subchapter, except for the following provisions: (1) Section 19.1705(a) of this title (relating to General Standards of Utilization Review);(2) Section 19.1706(a), (c), and (d) of this title (relating to Requirements and Prohibitions Relating to Personnel);(3) Section 19.1710 of this title (relating to Requirements Prior to Issuing Adverse Determination); and(4) Section 19.1711(a)(4) - (6) of this title (relating to Written Procedures for Appeal of Adverse Determination).(d) Utilization review plan. A specialty URA must have its utilization review plan, including appeal requirements, reviewed by a health care provider of the appropriate specialty who is licensed or otherwise authorized to provide the specialty health care service in Texas, and the plan must be implemented under standards developed with input from a health care provider of the appropriate specialty who is licensed or otherwise authorized to provide the specialty health care service in Texas. The specialty URA must have written procedures to ensure that these requirements are implemented.(e) Requirements of employed or contracted physicians, doctors, other health care providers, and personnel. (1) Physicians, doctors, other health care providers, and personnel employed by or under contract with the specialty URA to perform utilization review must be appropriately trained, qualified, and currently licensed.(2) Personnel conducting specialty utilization review must hold an unrestricted license, an administrative license issued by a state licensing board, or be otherwise authorized to provide health care services by a licensing agency in the United States.(f) Reasonable opportunity for discussion. In any instance in which a specialty URA questions the medical necessity, the appropriateness, or the experimental or investigational nature of the health care services, the health care provider of record must, prior to the issuance of an adverse determination, be afforded a reasonable opportunity to discuss the plan of treatment for the patient and the clinical basis for the decision of the URA with a health care provider of the same specialty as the URA. The discussion must include, at a minimum, the clinical basis for the specialty URA's decision and a description of documentation or evidence, if any, that can be submitted by the provider of record that, on appeal, might lead to a different utilization review decision. (1) The specialty URA's telephone number must be provided to the provider of record so that the provider of record may contact the specialty URA to discuss the pending adverse determination. For a retrospective utilization review, the specialty URA must allow the provider of record five working days to respond orally or in writing.(2) The specialty URA must maintain, and submit to TDI on request, documentation that details the discussion opportunity provided to the provider of record, including the date and time the specialty URA offered the opportunity to discuss the adverse determination; the date and time that the discussion, if any, took place; and the discussion outcome.(g) Appeal. The decision in any appeal of an adverse determination by a specialty URA must be made by a physician or other health care provider who has not previously reviewed the case and who is of the same specialty as the specialty URA that made the adverse determination.28 Tex. Admin. Code § 19.1716
The provisions of this §19.1716 adopted to be effective February 20, 2013, 38 TexReg 892; Amended by Texas Register, Volume 46, Number 11, March 12, 2021, TexReg 1647, eff. 3/17/2021