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§ 180.76. Rights and Responsibilities of Persons Involved in the Medical Quality Review Process

(a) The person subject to the medical quality review process has the right:

(1) to be notified that the person has been selected for the medical quality review process;

(2) to be notified of the disposition of the medical quality review process;

(3) to communicate with the office of the medical advisor at any time during the medical quality review process;

(4) to be represented by legal counsel, including legal counsel at the informal settlement process (ISC); and

(5) to an ISC in accordance with the provisions of this section. The ISC provides persons subject to the medical quality review process an opportunity to discuss and resolve their medical case review with Arbiters. An ISC is available under the following conditions:

(A) The case has been referred to enforcement.

(B) The request for an ISC must be in writing.

(C) The division will notify the requestor of the scheduled date of the ISC.

(D) The requestor has the right to receive all documents given to the Arbiters for review for that particular case.

(E) All information the requestor wishes the Arbiters to consider at the ISC must be received by the division no later than 15 days before the ISC. The Arbiters may refuse to consider any information not timely received by the division.

(F) The requestor may request to reschedule the scheduled date of the ISC for good cause shown, in writing, as determined by an attorney from the division’s office of general counsel. Good cause means circumstances beyond the control of the requestor that reasonably prevent the requestor from attending the ISC and requesting that the ISC be rescheduled any sooner.

(G) If a requestor fails to attend an ISC as scheduled, the requestor forfeits his right to an ISC, but it does not preclude the requestor from discussing the requestor’s case with the medical advisor as set forth in paragraph (3) of this subsection, from entering into a Consent Order with the division, or from defending an enforcement case at the State Office of Administrative Hearings.

(b) A person subject to a medical case review must:

(1) provide records and information requested from the office of the medical advisor in the format and manner specified by the division;

(2) provide the records and information within the time period specified in the request; and

(3) attach an accurate and completed business records affidavit to the request for records and information.

The provisions of this §180.76 adopted to be effective January 1, 2013, 37 TexReg 8839.

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At a Glance:

Title:

§ 180.76. Rights and Responsibilities of Persons Involved in the Medical Quality Review Process

Title:

Title 28. Insurance

Status:

Current

Usage:

New Law Rule

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