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|0522 |
TX IRO Form |
Federal External Review Process Form |
FERP Form |
Utilization Review Agent Application LHL005|0923 |
LHL005 |
Attestation |
ATTEST |