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Request For A Review By An Independent Review Organization LHL009 - Texas
| Request For A Review By An Independent Review Organization Form. This is a Texas form and can be used in Employee Workers Compensation . |
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REQUEST FOR A REVIEW BY AN INDEPENDENT REVIEW ORGANIZATION (IRO) INSTRUCTIONS *EXTERNAL REVIEW PROCESS NEWS: http://www.tdi.texas.gov/bulletins/2011/cc50.html This form is being provided to you because your request for health care services has been denied as not medically necessary. You can now request that your case be reviewed by a health care provider who is totally independent of your health plan or insurance carrier. This is called an independent review by an independent review organization or "IRO." You, your health care provider, or someone acting on your behalf may file this form. Before you request an independent review you must first have appealed or requested reconsideration of the denial. Below are the time frames in which you must file for appeal or reconsideration: · · · For health cases, the time limit imposed by the health plan for filing an appeal must be reasonable. For Workers' Compensation Non-Network cases, you must request reconsideration by the workers' compensation insurance carrier or Utilization Review Agent (URA) that made the decision within 15 working days after you received the first denial. For Workers' Compensation Network cases, you must request reconsideration by the workers' compensation insurance carrier or URA that made the decision within 30 calendar days. Exceptions: · If you have a life threatening condition and services have not been received, you do not have to request an appeal or reconsideration before requesting an independent review. · If you are an injured employee and have paid for services out of pocket, you do not have to request reconsideration before requesting an independent review. · If you are an injured employee and services have been provided, you cannot request an independent review unless you have paid for the services. Here is what you must do to request an independent review of your case: · · · Complete the attached form (LHL009, Request for a Review by an Independent Review Organization). Sign the form so the IRO can receive your medical records (Not required for Workers' Compensation cases). Return the completed form to the company that sent you the denial letter as soon as possible. (For Workers' Compensation cases, you must return this form requesting an IRO within 45 calendar days). The company's address and/or fax number are either listed on page four of the form or on the denial letters. DO NOT SEND THIS FORM TO THE TEXAS DEPARTMENT OF INSURANCE. The company will forward your request for an IRO to the Texas Department of Insurance. Once the Texas Department of Insurance receives the request from the company, we will assign your case to an IRO. You will receive a letter from the Texas Department of Insurance identifying the IRO to whom your case has been assigned. The IRO has 20 days to make a decision for non life threatening cases and 8 days to make a decision for life threatening cases. The IRO will notify you of its decision. There is no cost to you for the independent review. (Exception for Workers' Compensation Non-Network only: A health care provider requesting a retrospective IRO review will be required to pay the IRO fee prior to the IRO beginning its review. However, if the IRO finds in favor of the health care provider, the health care provider will be reimbursed by the insurance carrier for the amount of the IRO fee.) You can call the Texas Department of Insurance (TDI) at 1-866-554-4926 for information if you have any questions about the independent review process. LHL009 Rev. 1/2012 page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Pursuant to 28 TAC §19.1710, this form is prescribed by TDI. COMPLETE THIS FORM BY TYPING OR PRINTING THE INFORMATION WITH BLACK INK REQUEST FORM REQUEST FOR A REVIEW BY AN INDEPENDENT REVIEW ORGANIZATION Today's Date: Month________________ Day_____________ Year__________ Name of Party Requesting IRO: Relationship to the Patient or Injured Employee: (Check one) _________________________________________ Self Person acting on behalf of patient or injured employee Print Last Name, First Name and Middle Initial Provider acting on behalf of patient or injured employee Provider that received the denial Sub claimant (Workers' Compensation only) REASON FOR REQUEST FOR REVIEW BY AN IRO Is the condition life-threatening? Is the review ordered by a Court? Check one: Check one: Yes No Yes No (This question does not apply if services have been received) DENIED SERVICES Describe the health care services that are being denied (include dates only if services have been performed): ____________________________________________________________________________________________ PATIENT/INJURED EMPLOYEE INFORMATION Health Plan or Claim Identification Number:_________________________________________________ (This number is usually found on the patient's ID card for health plans. The number identifies the patient to the insurance carrier. Enter the DWC claim number for workers' compensation cases.) Date of Birth:(month) ____________ (day) ______ (year)_____ Sex_____ Social Security Number ________-______-________ First Name__________________Middle Name ______________ Last Name _______________Suffix______ Street ______________________________________________ City_____________________ State_______ Zip code____________ Phone: ______-_______________ Fax: ______-_____________________ THIS FORM MUST BE RETURNED TO THE COMPANY THAT ACTUALLY ISSUED THE DENIAL. DO NOT RETURN THIS FORM TO TDI. LHL009 Rev. 1/2012 page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Pursuant to 28 TAC §19.1710, this form is prescribed by TDI. COMPLETE THIS FORM BY TYPING OR PRINTING THE INFORMATION WITH BLACK INK PROVIDER THAT RECEIVED THE DENIAL Name______________________________________ Federal Tax Identification Number ______________________ Street_____________________________________________ City_________________________ State_______ Zip code_________ Phone: _______-_________________ Fax: ______-_____________________ PROVIDER ACTING ON PATIENT'S/INJURED EMPLOYEE'S BEHALF (IF APPLICABLE) Name_______________________________________________ Federal Tax Identification Number ______________________ Street______________________________________ City___________________ State______ Zip ___________ Phone number: _______-_________________Fax number: ______-____________________ PERSON ACTING ON PATIENT or INJURED EMPLOYEE'S BEHALF (IF APPLICABLE) First Name___________________Middle Name ____________Last Name _____
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