URA Original Application Naming Convention

DOCUMENTS

NAMING CONVENTION

Exhibit 1: Summary of the Utilization Review Plan

1 UR Plan P&P

Attachment A: General Standards of Utilization Review

1A UR Standards P&P

Attachment B: Mental Health Process and Progress Notes

1B Mental Health P&P

Attachment C: Notice of Determinations Made in Utilization Review

1C AD P&P

Notice of Adverse Determination Letter

1C AD LTR

Attachment D: Requirements Prior to Issuing Adverse Determination

1D P2P P&P

Attachment E: Independent Review of Adverse Determination

1E IR of AD P&P

Attachment F: Preauthorization for Health Maintenance Organizations and Preferred Provider Benefit Plans

1F Preauth HMO & PPO P&P

Exhibit 2: Categories of Personnel

2 Personnel List

Exhibit 3: Appeal of Adverse Determinations

3 Appeal of AD

Appeal Acknowledgment Letter

3 ACK LTR

One-Page Appeal Form

3 1pg Form

Appeal Determination Letter

3 APPEAL LTR

IF there is separate letter for denial for step therapy; TIC Sec. 1369.0546(f)

3 APL STPTHRPY

IF there is separate letter for denial for drug formulary; TIC Sec. 1369.056

3 APL DRGFORM

IF there is separate letter for denial for Acquired Brain Injury (ABI); TIC Sec. 1352.006

3 APL ABI

Exhibit 4: Telephone Access

4 Phone Access

Exhibit 5: Organization Information

5 Org Info

Franchise Tax Account Status

5 Franchise Tax

TX Secretary of State

5 SOS

Organization Chart

5 ORG Chart

Letter of Good Standing

5 LTR of Good Standing

Exhibit 6: Biographical Information

6 Bio Info

Biographical Affidavit (submit each individual’s bio as a separate file, with the individual’s name).

6 Bio J. Doe

Fingerprints (IdentoGo Receipt) (submit each individual’s fingerprint receipt as a separate file, with the individual’s name).

6 IdentoGo J. Doe

Request for a Review by an Independent Review Organization (IRO) Instructions LHL009|0920

TX IRO Form

Federal External Review Process Form

FERP Form

Utilization Review Agent Application LHL005|0915

LHL005

Attestation

ATTEST