What is adverse determination in Texas Administrative Code?

(1) Adverse determination--A determination by a URA made on behalf of any payor that the health care services provided or proposed to be provided to an enrollee are not medically necessary or appropriate or are experimental or investigational.

What is an UR in workers' comp?

Utilization review (UR) is the process used by employers or claims administrators to review treatment to determine if it is medically necessary. All employers or their workers' compensation claims administrators are required by law to have a UR program.

When did the utilization review start?

Utilization management and utilization review, along with the concept of medical necessity, are vital factors that influence how healthcare providers operate. Utilization review was introduced in the 1960s to reduce overutilization of resources and identify waste.

What is an ura in health insurance?

Utilization Review Agents (URA) HMO information.

What is the purpose of a utilization review?

Utilization review helps determine if healthcare services are being used efficiently and appropriately to provide patients with the care they need. It also ensures that healthcare is administered through proven methods, delivered in the right setting, and provided by an appropriate healthcare provider.

Get Texas Lhl005 Form

Texas Department of Insurance Health and WC Network Certification & QA, Mail Code 103-6A 512-490-1013 fax IRO, MC 103-5A 512-490-1011 fax; WC Networks, MC 103-5B 512-490-1028 fax 333 Guadalupe.

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