INSTRUCTIONS FOR COMPLETING THE
COMMERCIAL HEALTH UTILIZATION REVIEW SUMMARY

Special Instructions:

• Please note that the summaries for CHIP and Workers' Compensation plans must be submitted in the summary tables specifically designated for CHIP and Workers' Compensation plans.

• Please do not submit any information related to health plans that are not subject to Texas Insurance Code art. 21.58A and TDI rules. Some of the health plans that are not subject to the statute are:

• Medicare Plans (traditional and managed care)

• Medicaid Plans

• ERISA self-funded plans

• Federal Employee Plans

• Church Plans

Contact Name & Contact Information: The person or persons named in this field must be the person or persons that can answer any and all questions related to the information provided in this form.

COMPLAINT SUMMARY DATA

Total Number of Complaints Regarding Administration: Examples of this type of complaint are: (1) copies of medical records not paid for; (2) too many calls from URA; (3) too many written requests or information by URA; and (4) opportunity for peer-to-peer prior to adverse determination not given to physician or provider.

Total Number of Complaints Regarding Qualifications of the URA's Personnel: Examples of this type of complaint are: (1) the reviewer that determined medical necessity was not qualified to make the determination; (2) non-clinical personnel requested clinical information; (3) the peer-to-peer discussion was conducted by non-clinical personnel; and (4) any complaints regarding the review by the URA (i.e. biased, unclear, omissions; mistakes about type of service requested).

Total Number of Complaints Regarding the Appeal and Complaint Process: Examples of this type of complaint are: (1) treating physician unable to discuss plan of treatment with utilization review physician; (2) no notice or incomplete notice of adverse determination; (3) no notice of clinical basis for adverse determination; (4) no description of the criteria used; and (5) written procedures for complaints and appeal not provided or explained.

URA REVIEW SUMMARY DATA

If the URA has not been delegated any of the functions listed enter zero and check the "not delegated" box after those functions.

Total Number of Utilization Reviews Performed:

• Represents the total number of requests for prospective and concurrent reviews of health care services for which the URA performed utilization reviews during the applicable calendar year. See definition of "utilization review" in 28 TAC §19.1703(34).

• Do include medical necessity reviews performed as part of the verification process.

• Do not include any requests for clarification of coverage under the enrollee's insurance contract or evidence of coverage (i.e. what is or is not covered under the enrollee's plan).

• Do not include retrospective reviews. See definition of "retrospective review" in 28 TAC §19.1703(32).

Total Number of Adverse Determinations:

• Represents the total number of adverse determinations issued by the URA during the applicable calendar year. See definition of "adverse determination" in 28 TAC §19.1703(4). This number is a subset of the "total number of utilization reviews performed" listed in Field 8.

• Do not include any denials based on contract exclusions.

• Do not include denials after performance of retrospective reviews.

Note: Fields 10-16 relate to appeals of adverse determinations. If the URA has not been delegated the appeal function, enter "Not Delegated" after each field.

Total Number of Appeals of Adverse Determinations: Represents the total number of internal appeals of adverse determinations received by the URA during the applicable calendar year. This number is a subset of the "total number of adverse determinations" listed in Field 9.

Total Number of Appeals from Physicians and Providers: Represents appeals submitted by physicians and providers.

Total Number of Appeals from Enrollees: Represents appeals submitted by enrollees (patients)

Total Number of Appeals from Other Sources: Represents appeals submitted by enrollee representatives such as parents and attorneys.

Total Number of Appeals Overturned: Represents the number of appeals that resulted in reversals of the original adverse determinations and the URA ultimately approved the services or treatment.

Total Number of Appeals Partially Overturned/Upheld: Represents the number of appeals that resulted in the reversals of part or parts of the original adverse determinations and the URA ultimately approved some of the services or treatment but denied the remaining services or treatment requested.

Total Number of Appeals Upheld: Represents the number of appeals that resulted in decisions to maintain the original adverse determinations and the URA continues to deny the services or treatment.

Note: Fields 17-20 relate to independent review of adverse determinations. If the URA has not been delegated the function to submit IRO requests to TDI, enter "Not Delegated" after each field.

Total Number of Independent Reviews Requested: Represents the number of requests received by the URA from physicians, providers, enrollees, and persons acting on behalf of enrollees requesting independent reviews by the independent review organization (IRO).

Total Number Overturned: Represents the number of IRO reviews that resulted in reversals of the URA's adverse determinations.

Total Number Partially Overturned/Upheld: Represents the number of reviews that resulted in both reversals of and agreements with the URA's adverse determinations. For example, the IRO determines that 2 out of the 3 denied hospital days were medically necessary. In this example, the IRO upholds the URA's determination that 1 of the 3 hospital days was not medically necessary but overturns the URA's determination that 2 of the 3 hospital days were not medically necessary.

Total Number Upheld: Represents the number of reviews that resulted in the IRO's agreements with the URA's adverse determinations.

Instructions for Information Required in the

"Commercial Health Utilization Review Summary" Table

Adverse Determinations by ICD-9 or DSM-IV Codes:

• List the top 25 ICD-9 or DSM-IV Codes (up to the 4^th digit) that were denied by the URA in the field designated "Field Number 21: ICD-9/DSM-IV Code."

• Each ICD-9 or DSM-IV Code must be listed in its own row

Total Number of Adverse Determinations for Each ICD-9 or DSM-IV Code:

• List the total number of adverse determinations for each ICD-9/DSM-IV Code listed in the corresponding row (Field 21)

• Each total for each ICD-9 or DSM-IV Code must be listed in its own row.

Appeals by ICD-9 or DSM-IV Codes:

• List the top 25 ICD-9 or DSM-IV Codes (up to the 4^th digit) that were appealed to the URA in the field designated "Field Number 23: ICD-9/DSM-IV Code."

• Each ICD-9 or DSM-IV Code must be listed in its own row

Total Number of Appeals for Each ICD-9 or DSM-IV Code:

• List the total number of appeal denials for each ICD-9/DSM-IV Code listed in the corresponding row (Field 23)

• Each total for each ICD-9 or DSM-IV Code must be listed in its own row.

Adverse determinations by CPT codes:

• List the top 50 CPT codes that were denied by the URA in the field designated "Field Number 25: CPT Code."

• Each CPT code must be listed in its own row.

Total Number of Adverse Determinations for Each CPT Code

• List the total number of adverse determinations for each CPT Code listed in the corresponding row (Field 25)

• Each total for each CPT Code must be listed in its own row.

Appeals by CPT codes:

• List the top 50 CPT Codes (up to the 4^th digit) that were appealed to the URA in the field designated "Field Number 27: CPT Code."

• Each CPT Code must be listed in its own row

Total Number of Appeals for Each CPT Code:

• List the total number of appeal denials for each CPT Code listed in the corresponding row (Field 27)

• Each total for each CPT Code must be listed in its own row.