| Exhibit 1: Categories of Personnel |
1 Personnel List |
| Exhibit 2: Adverse Determination (AD) Template Letters (3 types, listed below) |
| Initial AD Letter |
2 Initial AD |
| IF there is separate letter for denial for step therapy; TIC Sec. 1369.0546(f) |
2 Initial STPTHRPY |
| IF there is separate letter for denial for drug formulary; TIC Sec. 1369.056 |
2 Initial DRGFORM |
| IF there is separate letter for denial for Acquired Brain Injury (ABI); TIC Sec. 1352.006 |
2 Initial ABI |
| AD Appeal Acknowledgement Letter |
2 Appeal Ack |
| AD Appeal Determination Letter |
2 Appeal AD |
| IF there is separate letter for denial for step therapy; TIC Sec. 1369.0546(f) |
3 Appeal STPTHRPY |
| IF there is separate letter for denial for drug formulary; TIC Sec. 1369.056 |
3 Appeal DRGFORM |
| IF there is separate letter for denial for Acquired Brain Injury (ABI); TIC Sec. 1352.006 |
3 Appeal ABI |
| Template Letters Attestation |
ATTEST |
| 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 |
