DWC Proposes Rules on UR Credentialing and EDI Reporting Standards

The Texas Division of Workers’ Compensation has published two rule initiatives designed to implement a legislative change mandating UR credentialing changes as well as to shift EDI claims reporting standards from IAIABC Release 1 to Release 3.1. Both proposed rule initiatives have been posted for review and comment by system stakeholders.

Background on Proposed Amendment to UR Credentialing Rule

During the 2019 legislative session the Legislature passed Senate Bill 1742, which amended Texas Labor Code §408.0043 and became effective September 1, 2019. Senate Bill 1742 amended portions of the Texas Insurance Code and the Texas Labor Code in several ways, some of which affect the manner in which Utilization Review, Independent Review and Peer Review can be conducted in Texas. Portions of the bill apply directly to Texas workers’ compensation claims both in and out of Health Care Networks.

The bill implemented two broad changes. First, it imposed a Texas licensure requirement in a number of different areas. Second, it required that doctors performing peer reviews, utilization reviews or independent reviews be of the same or a similar specialty as the physician performing the service. For workers’ comp purposes, the bill requires that doctors hold Texas licenses in the following instances:

    • Where a utilization review agent or an insurance carrier uses doctors to perform reviews of health care services in connection with an HCN. Amending § 1305.351(d).
    • Where an independent review organization uses doctors to perform reviews of health care services in connection with an HCN. Amending § 1305.355(d).
    • Where a utilization review agent or an insurance carrier uses doctors to perform reviews of health care services provided under the Texas Workers’ Compensation Act, including utilization review. Amending § 408.023(h).
    • Where an independent review organization uses doctors to perform reviews of health care services provided under the Texas Workers’ Compensation Act. Amending § 413.031(e-2).

In addition, an amendment to § 408.0043 required a peer review doctor or a doctor performing utilization review of a health care service or independent review of a health care service to be of the same or a similar specialty as the physician whose service is being reviewed.

DWC’s Proposed Rule Amendment for UR Credentialing

The Division announced a proposed amendment to Rule 180.1, which purport to conform the definition of appropriate credentials with Texas Labor Code §408.0043(c). The proposed rule amendment will require physicians who perform utilization review, independent review, and peer review in the workers’ compensation system to have the same or similar specialty as the physician whose requested medical service is under review.

The proposed rule will be published in the November 27, 2020, issue of the Texas Register and will be available at www.sos.state.tx.us/texreg/index.shtml once published. The Division will also post a copy of the proposed rule at www.tdi.texas.gov/wc/rules/2020rules.html.

Interested parties may submit written comments on the proposed rule to: RuleComments@tdi.texas.gov, or may mail or deliver comments to:

Cynthia Guillen
DWC Legal Services, MS-4D
Texas Department of Insurance, Division of Workers’ Compensation
7551 Metro Center Drive, Suite 100
Austin, Texas 78744-1645

The deadline to submit comments is 5 p.m., Central time, on December 28, 2020.

Flahive, Ogden & Latson strongly recommends that carriers review their utilization review, independent review and peer review processes to assure compliance with §408.0043 and any rules that may be amended through this process.

Replacing EDI Claims Reporting Standards

The Division has also informally proposed amendments to Rules 124.2, 102.4, 102.5, and 102.8, as well as a new Subchapter B in the Chapter 124 Rules, which the agency states will update and enhance its data collection methods.

DWC staff recently completed an evaluation of the most recent standards for collecting claim information to see which is most suitable for EDI. By rule, DWC currently uses the International Association of Industrial Accident Boards and Commissions reporting standard Release 1. DWC has used this standard since 1994.

IAIABC recently updated its claims reporting standard to Release 3.1, which the Division believes would provide the update the agency needs. DWC says the new standard would “replace an outdated claims EDI standard that is no longer supported by the IAIABC and align the claims EDI standard in Texas with the standard used in several other states.”

To implement the IAIABC Release 3.1 claims reporting standards, DWC must adopt rules. DWC is specifically requesting feedback from system participants on the cost and time frame needed to comply with the new data collection standard.

The Division of Workers’ Compensation will host a virtual stakeholder meeting to discuss the amendments on Wednesday, December 16, 2020, at 10 a.m., Central time, through Zoom. Information on how to connect to the meeting will be available on the TDI website. Any written comments to the proposed rules must be delivered to the Division, at the email or physical addresses listed above, no later than 5 p.m., Central Time on Monday, December 21, 2020.