The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise:
(1) Adverse determination–A determination by a utilization review agent made on behalf of a payor that the health care services provided or proposed to be provided to an injured employee are not medically necessary or appropriate. The term does not include a denial of health care services due to the failure to request prospective or concurrent utilization review. An adverse determination does not include a determination that health care services are experimental or investigational.
(2) Agent–A person whom a system participant utilizes or contracts with for the purpose of providing claims service or fulfilling medical bill processing obligations under Labor Code, Title 5 and rules. The system participant who utilizes or contracts with the agent may also be responsible for the administrative violations of that agent. This definition does not apply to “agent” as used in the term “pharmacy processing agent.”
(3) Bill review–Review of any aspect of a medical bill, including retrospective review, in accordance with the Labor Code, the Insurance Code, division or department rules, and the appropriate fee and treatment guidelines.
(4) Complete medical bill–A medical bill that contains all required fields as set forth in the billing instructions for the appropriate form specified in § 133.10 of this chapter (relating to Required Billing Forms/Formats), or as specified for electronic medical bills in § 133.500 of this chapter (relating to Electronic Formats for Electronic Medical Bill Processing).
(5) Emergency–Either a medical or mental health emergency as follows:
(A) a medical emergency is the sudden onset of a medical condition manifested by acute symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected to result in:
(i) placing the patient’s health or bodily functions in serious jeopardy, or
(ii) serious dysfunction of any body organ or part;
(B) a mental health emergency is a condition that could reasonably be expected to present danger to the person experiencing the mental health condition or another person.
(6) Final action on a medical bill–
(A) sending a payment that makes the total reimbursement for that bill a fair and reasonable reimbursement in accordance with § 134.1 of this title (relating to Medical Reimbursement); and/or
(B) denying a charge on the medical bill.
(7) Pharmacy processing agent–A person or entity that contracts with a pharmacy in accordance with Labor Code § 413.0111, establishing an agent or assignee relationship, to process claims and act on behalf of the pharmacy under the terms and conditions of a contract related to services being billed. Such contracts may permit the agent or assignee to submit billings, request reconsideration, receive reimbursement, and seek medical dispute resolution for the pharmacy services billed.
(8) Reasonable opportunity–At least one documented good faith attempt to contact the provider of record that provides an opportunity for the provider of record to discuss the services under review with the utilization review agent during normal business hours prior to issuing a prospective, concurrent, or retrospective utilization review adverse determination:
(A) no less than one working day prior to issuing a prospective utilization review adverse determination;
(B) no less than five working days prior to issuing a retrospective utilization review adverse determination; or
(C) prior to issuing a concurrent or post-stabilization review adverse determination.
(9) Retrospective utilization review–A form of utilization review for health care services that have been provided to an injured employee. Retrospective utilization review does not include review of services for which prospective or concurrent utilization reviews were previously conducted or should have been previously conducted.
The provisions of this §133.2 adopted to be effective May 2, 2006, 31 TexReg 3544; amended to be effective July 27, 2008, 33 TexReg 5701; amended to be effective July 1, 2012, 37 TexReg 2408; amended to be effective March 30, 2014, 39 TexReg 2095.