| FIN306
|
Officers and Directors Page
Complete Listing of all Current Officers and Directors
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PDF |
English |
| LHL005
|
URA Application Form
Application to apply for URA Certification, renew a URA Certification or update a URA Certification.
|
PDF |
English |
| LHL006
|
IRO Application
Application to apply for IRO Certification, renew an IRO Certification or update an IRO Certification
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PDF |
English |
| LHL007
|
Supplemental Certification for IRO Renewal
Attach this form to the renewal application. You can attach it in the online renewal form or with the IRO Application, Form LHL006.
|
PDF |
English |
| LHL009
|
Request for Review by an IRO
Form used by Patients/Injured Employees or persons acting on their behalf or health care providers to request a review by an Independent Review Organization (IRO) for disputes of medical necessity
|
PDF |
English |
| LHL009 Spanish
|
Solicitud para una revisión por parte de una Organización de Revisión Independiente
[En Español] - Solicitud para pedir una revisión por parte de una Organización de Revisión Independiente (Independent Review Organization- IRO por su nombre y siglas en inglés) para las disputas médicas necesarias de pacientes, empleados lesionados, representantes del paciente o proveedores de atención médica.
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PDF |
Spanish |
| LHL011
|
Notice of Rescission of Preauthorization Exemption and Right to Request an Independent Review
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PDF |
English |
| LHL234
|
Application Package
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PDF |
English |
| LHL234a
|
Other Professional Degrees
Attachment A
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PDF |
English |
| LHL234b
|
Other Post-Graduate Education
Attachment B
|
PDF |
English |
| LHL234c
|
Other Work History
Attachment C
|
PDF |
English |
| LHL234d
|
Other Current Hospital Affiliations
Attachment D
|
PDF |
English |
| LHL234e
|
Other Previous Hospital Affiliations
Attachment E
|
PDF |
English |
| LHL234f
|
Other Practice Locations
Attachment F
|
PDF |
English |
| LHL234g
|
Malpractice Claims History
Attachment G
|
PDF |
English |
| LHL658
|
Application for Approval Exclusive Provider Benefit Plan (EPO) and Preferred Provider Benefit Plan (PPO)
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PDF |
English |
| LHL705
|
Workers’ Compensation Health Care Network Application
|
PDF |
English |
| LHL707
|
HMO Network Access Plan Requirements
|
PDF |
English |
| LHL708
|
Workers' Compensation Network Access Plan Checklist
WC Network Access Plan Checklist
|
PDF |
English |
| LHL709
|
Certification of Independence and Qualifications of the Reviewer
|
PDF |
English |
| LHL710
|
Holder of Bonds or Notes Over $100,000
|
PDF |
English |
| LHL711
|
Addendum to Biographical Affidavit
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PDF |
English |
| LHL712
|
IRO Notice of Decision Template - HC
|
WORD |
English |
| LHL713
|
IRO Notice of Decision Template - WC
|
WORD |
English |
| LHL714
|
IRO Notice of Decision Template - Rescission
|
WORD |
English |
| LHL715
|
Provider Network Contracting Entity Registration and Exemption of Affiliates Form
PNCE Registration and Exemption Form
|
PDF |
English |
| LHL716
|
Health Maintenance Organization Annual Network Adequacy Report and Access Plan Checklist
|
PDF |
English |
| LHL717
|
Utilization Review Agent's (URA) Designated Contact for IRO Requests
|
PDF |
English |
| LHL718
|
Health Maintenance Organization (HMO) Physician / Provider Contract Requirements
Used as guide to indicate the mandatory provisions and benefits required in a Provider Contract
|
PDF |
English |
| LHL719
|
HMO Delegation Agreement Checklist
|
PDF |
English |
| LHL720
|
Workers' Compensation Health Care Network Provider Contract Checklist
|
PDF |
English |
| LHL721
|
Workers’ Compensation Network Contract with Insurance Carrier Contract Requirements Checklist
|
PDF |
English |
| LHL722
|
Workers' Compensation Health Care Network Management Contract Checklist
|
PDF |
English |
| NOFR001
|
Prior Authorization of Health Care Services
|
PDF |
English |
| NOFR002
|
Texas Standard Prior Authorization Request Form for Prescription Drug Benefits
|
PDF |
English |
| SN002
|
Notice to HMO Enrollees: Have a complaint about your HMO?
|
PDF |
English |
| SN002s
|
¿Tiene una queja relacionada con su HMO?
|
PDF |
Spanish |
| SN003
|
Workers Comp Network Sample Contingency Plan
|
PDF |
English |
| SN004
|
Workers Comp Net Sample Employee Acknowledgment Form
|
PDF |
English |
| SN005
|
Workers Comp Net Employee Acknowledgment Form
|
PDF |
Spanish |
| SN006
|
Workers Comp Net Sample Employee Acknowledgment Form - Chinese
|
PDF |
Chinese |
| SN007
|
Workers Comp Net Sample Employee Acknowledgment Form
|
PDF |
Vietnamese |
| SN008
|
Workers Comp Network Sample QI Report
|
PDF |
English |
| SN009
|
Sample URA Adverse Determination Notice, Health
|
PDF |
English |
| SN010
|
Sample URA Adverse Determination Notice, Specialty Health
|
PDF |
English |
| SN011
|
Sample URA Adverse Determination Notice, Workers Comp Net
|
PDF |
English |
| SN012
|
Sample URA Adverse Determination Notice, Workers Comp Non-Network
|
PDF |
English |
| SN013
|
Contract List
|
PDF |
English |
| SN014
|
Delegated Entity Data Form
Sample format for use by HMOs and WC HCNs when submitting delegation agreements to the Texas Department of Insurance
|
PDF |
English |
