(a) The purpose of this section is to provide a prescribing doctor or pharmacy an ability to obtain an medical interlocutory order (MIO) in instances where preauthorization denials of a previously prescribed and dispensed drug(s) excluded from the closed formulary poses an unreasonable risk of a medical emergency as defined in § 134.500(7) of this title (relating to Definitions) and Insurance Code § 1305.004(a)(13).
(b) A request for an interlocutory order that does not meet the criteria described by this section may still be requested pursuant to § 133.306 of this title (relating to Interlocutory Order for Medical Benefits).
(c) An MIO will be issued if the request for an MIO contains the following information:
(1) injured employee name;
(2) date of birth of injured employee;
(3) prescribing doctor’s name;
(4) name of drug and dosage;
(5) MIO requestor’s name (pharmacy or prescribing doctor);
(6) MIO requestor’s contact information;
(7) a statement that a preauthorization request for a previously prescribed and dispensed drug(s), which is excluded from the closed formulary, has been denied by the insurance carrier;
(8) a statement that an independent review request has already been submitted to the insurance carrier or the insurance carrier’s utilization review agent in accordance with § 133.308 of this title (relating to MDR by Independent Review Organizations);
(9) a statement that the preauthorization denial poses an unreasonable risk of a medical emergency as defined in § 134.500(7) of this title;
(10) a statement that the potential medical emergency has been documented in the preauthorization process;
(11) a statement that the insurance carrier has been notified that a request for an MIO is being submitted to the division; and
(12) a signature and the following certification by the MIO requestor for paragraphs (7)-(12) of this subsection, “I hereby certify under penalty of law that the previously listed conditions have been met.”
(d) A complete request for an MIO under this section shall be processed and approved by the division in accordance with this section. At the discretion of the division, an incomplete request for an MIO under this section may be considered in accordance with this section.
(e) The request for an MIO may be submitted on the designated division form available on the Texas Department of Insurance’s website, http://www.tdi.state.tx.us/wc/indexwc.html. In the event the division form is not available, the written request must contain the provisions of subsection (c) of this section.
(f) The MIO requestor shall provide a copy of the MIO request to the insurance carrier, prescribing doctor, injured employee, and dispensing pharmacy, if known, on the date the request for MIO is submitted to the division.
(g) An approved MIO shall be effective retroactively to the date the complete request for an MIO is received by the division.
(h) Notwithstanding § 133.308 of this title:
(1) A request for reconsideration of a preauthorization denial is not required prior to a request for independent review when pursuing an MIO under this section. If a request for reconsideration or an MIO request is not initiated within 15 days from the initial preauthorization denial, then the opportunity to request an MIO under this section does not apply.
(2) If pursuing an MIO after denial of a reconsideration request, a complete MIO request shall be submitted within five working days of the reconsideration denial.
(i) An appeal of the independent review organization (IRO) decision relating to the medical necessity and reasonableness of the drugs contained in the MIO shall be submitted in accordance with § 133.308(t) of this title.
(j) The MIO shall continue in effect until the later of:
(1) final adjudication of a medical dispute regarding the medical necessity and reasonableness of the drug contained in the MIO;
(2) expiration of the period for a timely appeal; or
(3) agreement of the parties.
(k) Withdrawal by the requestor of a request for medical necessity dispute resolution constitutes acceptance of the preauthorization denial.
(l) A party shall comply with an MIO entered in accordance with this section and the insurance carrier shall reimburse the pharmacy for prescriptions dispensed in accordance with an MIO.
(m) The insurance carrier shall notify the prescribing doctor, injured employee, and the dispensing pharmacy once reimbursement is no longer required in accordance with subsection (j) of this section.
(n) Payments made by insurance carriers pursuant to this section may be eligible for reimbursement from the Subsequent Injury Fund in accordance with Labor Code § 410.209 and § 413.055, and applicable rules.
(o) A decision issued by an IRO is not an agency or commissioner decision.
(p) A party may seek to reverse or modify an MIO issued under this section if:
(1) a final determination of medical necessity has been rendered; and
(2) the party requests a benefit contested case hearing (CCH) from the division’s chief clerk no later than 20 days after the date the IRO decision is sent to the party. A benefit review conference is not a prerequisite to a division CCH under this subsection. Except as provided by this subsection, a division CCH shall be conducted in accordance with Chapters 140 and 142 of this title (relating to Dispute Resolution–General Provisions and Dispute Resolution–Benefit Contested Case Hearing).
(q) The insurance carrier may dispute an interlocutory order entered under this title by filing a written request for a hearing in accordance with Labor Code § 413.055 and § 148.3 of this title (relating to Requesting a Hearing).
The provisions of this §134.550 adopted to be effective January 17, 2011, 35 TexReg 11344.