(a) Qualification requirements. Physicians, doctors, and other health care providers employed by or under contract with a URA to perform utilization review must be appropriately trained, qualified, and currently licensed. Personnel conducting utilization review must hold an unrestricted license, an administrative license, or be otherwise authorized to provide health care services by a licensing agency in the United States.
  (1) This subchapter does not supersede requirements in the Medical Practice Act; Texas Medical Board rules; Texas Occupations Code Chapter 201 (relating to Chiropractors); or Texas Board of Chiropractic Examiners rules. Individuals licensed by the Texas Medical Board are subject to 22 TAC Chapter 190, regarding disciplinary guidelines.
  (2) Personnel who perform clerical or administrative tasks are not required to have the qualifications prescribed by this subsection.
(b) Disqualifying associations. For purposes of this subsection, being employed by or under contract with the same URA as the physician, doctor, or other health care provider who issued the initial adverse determination does not in itself constitute a disqualifying association. A physician, doctor, or health care provider who conducts utilization review must not have any disqualifying associations with the:
  (1) enrollee or health care provider who is requesting the utilization review or an appeal; or
  (2) physician, doctor, or other health care provider who issued the initial adverse determination.
(c) Information to be sent to TDI. The URA must send to TDI the name, type, license number, state of licensure, and qualifications of the personnel either employed or under contract to perform the utilization review with an original or renewal application.
(d) Written procedures and maintenance of records. URAs must develop and implement written procedures and maintain documentation to demonstrate that all physicians, doctors, and other health care providers used by the URA are licensed, qualified, and appropriately trained or experienced.
(e) Training related to acquired brain injury treatment. A URA must provide adequate training to personnel responsible for precertification, certification, and recertification of services or treatment relating to acquired brain injury in accord with Insurance Code §1352.004. The purpose of the training is to prevent denial of coverage in violation of Insurance Code §1352.003 and to avoid confusion of medical benefits with mental health benefits.

Source Note: The provisions of this §19.1706 adopted to be effective February 20, 2013, 38 TexReg 892