SECTION 19.1707. URA Contact with and Receipt of Information from Health Care Providers

(a) If a URA must reimburse health care providers for providing medical information under Insurance Code §4201.207, reimbursement is limited to the reasonable costs for providing medical records relevant to the utilization review that were requested by the URA in writing. A health care provider's charge for providing medical information to a URA must comply with §134.120 of this title (relating to Reimbursement for Medical Documentation) and may not include any costs that are recouped as a part of the charge for health care.

(b) When conducting routine utilization review, the URA must request all relevant and updated information and medical records to complete the review.

(1) This information may include identifying information about the enrollee; the benefit plan or claim; the treating physician, doctor, or other health care provider; and the facilities rendering care. It may also include clinical and diagnostic testing information regarding the diagnoses of the enrollee and the medical history of the enrollee relevant to the diagnoses; the enrollee's prognosis; and the plan of treatment prescribed by the provider of record, along with the provider of record's justification for the plan of treatment. The required information should be obtained from the appropriate source.

(2) URAs must not routinely request copies of all medical records on enrollees reviewed. During utilization review, copies of the necessary or pertinent sections of medical records should only be required when a difficulty develops in determining whether the health care is medically necessary or appropriate, or experimental or investigational.

(c) The URA must share among its various divisions all clinical and demographic information on individual enrollees to avoid duplicate requests for information from enrollees, physicians, doctors, and other health care providers.

(d) A URA may not require as a condition of approval of a health care service, or for any other reason, the observation of a psychotherapy session or the submission or review of a mental health therapist's process or progress notes that relate to the mental health therapist's treatment of an enrollee's mental or emotional condition or disorder. This prohibition extends to requiring an oral, electronic, facsimile, or written submission or rendition of a mental health therapist's process or progress notes. This prohibition does not preclude the URA from requiring submission of:

(1) an enrollee's mental health medical record summary; or

(2) medical records or process or progress notes that relate to treatment of conditions or disorders other than a mental or emotional condition or disorder.

Source Note: The provisions of this §19.1707 adopted to be effective February 20, 2013, 38 TexReg 892