Section 134.550 - Medical Interlocutory Order(a) The purpose of this section is to provide a prescribing doctor or pharmacy an ability to obtain a medical interlocutory order when preauthorization denials of previously prescribed and dispensed drugs excluded from the closed formulary pose an unreasonable risk of a medical emergency as defined in § 134.500(7) of this title (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 submitted under § 133.306 of this title (Interlocutory Orders for Medical Benefits).(c) A request for a medical interlocutory order must contain 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) requester's name (pharmacy or prescribing doctor);(6) requester's contact information;(7) a statement that a preauthorization request for a previously prescribed and dispensed drug, 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 under § 133.308 of this title (MDR of Medical Necessity Disputes);(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 a medical interlocutory order is being submitted to the division; and(12) a signature and the following certification by the medical interlocutory order requester for paragraphs (7) - (12) of this subsection, "I hereby certify under penalty of law that the previously listed conditions have been met."(d) The division will process and approve a complete request for a medical interlocutory order under this section. At its discretion, the division may consider an incomplete request for a medical interlocutory order.(e) The request for a medical interlocutory order must be in writing and must contain the information in subsection (c) of this section. A convenient form that contains the required information is on the division's website at https://www.tdi.texas.gov/forms/form20numeric.html.(f) The requester must provide a copy of the request to the insurance carrier, prescribing doctor, injured employee, and dispensing pharmacy, if known, on the date the requester submits the request to the division.(g) An approved medical interlocutory order is effective retroactively to the date the division received the complete request for the medical interlocutory order.(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 a medical interlocutory order under this section. If a request for reconsideration or a medical interlocutory order request is not initiated within 15 days from the initial preauthorization denial, then the opportunity to request a medical interlocutory order under this section does not apply.(2) If pursuing a medical interlocutory order after denial of a reconsideration request, a complete medical interlocutory order must 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 medical interlocutory order must be submitted under § 133.308(t) of this title.(j) The medical interlocutory order continues in effect until the later of: (1) final adjudication of a medical dispute about the medical necessity and reasonableness of the drug contained in the medical interlocutory order;(2) expiration of the period for a timely appeal; or(3) agreement of the parties.(k) If a requester withdraws a request for medical necessity dispute resolution, the requester accepts the preauthorization denial.(l) A party must comply with a medical interlocutory order entered under this section, and the insurance carrier must reimburse the pharmacy for prescriptions dispensed under a medical interlocutory order.(m) The insurance carrier must notify the prescribing doctor, injured employee, and the dispensing pharmacy once reimbursement is no longer required under subsection (j) of this section.(n) Payments made by insurance carriers under this section may be eligible for reimbursement from the subsequent injury fund under 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 a medical interlocutory order 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 must be conducted under Chapters 140 and 142 of this title (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 under Labor Code §413.055 and § 148.3 of this title (Requesting a Hearing).28 Tex. Admin. Code § 134.550
The provisions of this §134.550 adopted to be effective January 17, 2011, 35 TexReg 11344; Amended by Texas Register, Volume 49, Number 48, November 29, 2024, TexReg 9760, eff. 11/28/2024