| (G) an explanation of why the disputed amount should
be refunded or reimbursed, and how the submitted documentation supports
the explanation for each disputed amount;
(H) proof of employee payment (including copies of
receipts, health care provider billing statements, or similar documents);
and
(I) a copy of the insurance carrier's or health care
provider's denial of reimbursement or refund relevant to the dispute,
or if no denial was received, convincing evidence of the injured employee's
attempt to obtain reimbursement or refund from the insurance carrier
or health care provider.
(5) Division Response to Request. The division will
forward a copy of the request and the documentation submitted in accordance
with paragraph (2), (3), or (4) of this subsection to the respondent.
The respondent shall be deemed to have received the request on the
acknowledgment date as defined in §102.5 of this title (relating
to General Rules for Written Communications to and from the Commission).
(d) Responses. Responses to a request for MFDR must
be legible and submitted to the division and to the requestor in the
form and manner prescribed by the division.
(1) Timeliness. The response will be deemed timely
if received by the division through mail service, personal delivery,
or electronic transmission, as described in §102.5 of this title,
within 14 calendar days after the date the respondent received the
copy of the requestor's dispute. If the division does not receive
the response information within 14 calendar days of the dispute notification,
then the division may base its decision on the available information.
(2) Response. On receipt of the request, the respondent
must provide any missing information not provided by the requestor
and known to the respondent. The respondent must also provide the
following information and records:
(A) the name, address, and contact information of the
respondent;
(B) all initial and appeal EOBs related to the dispute
as originally submitted to the health care provider in accordance
with this chapter, related to the health care in dispute not submitted
by the requester, or a statement certifying that the respondent did
not receive the health care provider's disputed billing before the
dispute request;
(C) all medical bill(s) related to the dispute, submitted
in accordance with this chapter if different from that originally
submitted to the insurance carrier for reimbursement;
(D) any pertinent medical records or other documents
relevant to the fee dispute not already provided by the requestor;
(E) a statement of the disputed fee issue(s), which
includes:
(i) a description of the health care in dispute;
(ii) a position statement of reasons why the disputed
medical fees should not be paid;
(iii) a discussion of how the Labor Code and division
rules, including fee guidelines, impact the disputed fee issues;
(iv) a discussion regarding how the submitted documentation
supports the respondent's position for each disputed fee issues;
(v) documentation that discusses, demonstrates, and
justifies that the amount the respondent paid is a fair and reasonable
reimbursement in accordance with Labor Code §413.011 and §134.1
or §134.503 of this title if the dispute involves health care
for which the division has not established a MAR or reimbursement
rate, as applicable.
(F) The responses shall address only those denial reasons
presented to the requestor prior to the date the request for MFDR
was filed with the division and the other party. Any new denial reasons
or defenses raised shall not be considered in the review. If the response
includes unresolved issues of compensability, extent of injury, liability,
or medical necessity, the request for MFDR will be dismissed in accordance
with subsection (f)(3)(B) or (C) of this section.
(G) If the respondent did not receive the health care
provider's disputed billing or the employee's reimbursement request
relevant to the dispute prior to the request, the respondent shall
include that information in a written statement.
(H) If the medical fee dispute involves compensability,
extent of injury, or liability, the insurance carrier must attach
any related Plain Language Notice in accordance with §124.2 of
this title (concerning Insurance Carrier Reporting and Notification
Requirements).
(I) If the medical fee dispute involves medical necessity
issues, the insurance carrier must attach documentation that supports
an adverse determination in accordance with §19.2005 of this
title (concerning General Standards of Utilization Review).
(e) Withdrawal. The requestor may withdraw its request
for MFDR by notifying the division prior to a decision.
(f) MFDR Action. The division will review the completed
request and response to determine appropriate MFDR action.
(1) Request for Additional Information. The division
may request additional information from either party to review the
medical fee issues in dispute. The additional information must be
received by the division no later than 14 days after receipt of this
request. If the division does not receive the requested additional
information within 14 days after receipt of the request, then the
division may base its decision on the information available. The party
providing the additional information shall forward a copy of the additional
information to all other parties at the time it is submitted to the
division.
(2) Issues Raised by the Division. The division may
raise issues in the MFDR process when it determines such an action
to be appropriate to administer the dispute process consistent with
the provisions of the Labor Code and division rules.
(3) Dismissal. A dismissal is not a final decision
by the division. The medical fee dispute may be submitted for review
as a new dispute that is subject to the requirements of this section.
The division may dismiss a request for MFDR if:
(A) the division determines that the medical bills
in the dispute have not been submitted to the insurance carrier for
an appeal, when required;
(B) the request contains an unresolved adverse determination
of medical necessity;
(C) the request contains an unresolved compensability,
extent of injury, or liability dispute for the claim; or
(D) the division determines that good cause exists
to dismiss the request, including a party's failure to comply with
the provisions of this section.
(4) Decision. The division shall send a decision to
the disputing parties or to representatives of record for the parties,
if any, and post the decision on the department's website.
(5) Division Fee. The division may assess a fee in
accordance with §133.305 of this subchapter (relating to MDR--General).
(g) Appeal of MFDR Decision. A party to a medical fee
dispute may seek review of the decision. Parties are deemed to have
received the MFDR decision as provided in §102.5 of this title.
The MFDR decision is final if the request for the benefit review conference
is not timely made. If a party provides the benefit review officer
or administrative law judge with documentation listed in subsection
(d)(2)(H) or (I) of this section that shows unresolved issues regarding
compensability, extent of injury, liability, or medical necessity
for the same service subject to the fee dispute, then the benefit
review officer or administrative law judge shall abate the proceedings
until those issues have been resolved.
(1) A party seeking review of an MFDR decision must
request a benefit review conference no later than 20 days from the
date the MFDR decision is received by the party. The party that requests
a review of the MFDR decision must mediate the dispute in the manner
required by Labor Code, Chapter 410, Subchapter B and request a benefit
review conference under Chapter 141 of this title (relating to Dispute
Resolution--Benefit Review Conference). A party may appear at a benefit
review conference via telephone. The benefit review conference will
be conducted in accordance with Chapter 141 of this title.
(A) Notwithstanding §141.1(b) of this title (relating
to Requesting and Setting a Benefit Review Conference), a seeking
review of an MFDR decision may request a benefit review conference.
(B) At a benefit review conference, the parties to
the dispute may not resolve the dispute by negotiating fees that are
inconsistent with any applicable fee guidelines adopted by the commissioner.
(C) A party must file the request for a benefit review
conference in accordance with Chapter 141 of this title and must include
in the request a copy of the MFDR decision. Providing a copy of the
MFDR decision satisfies the documentation requirements in §141.1(d)
of this title. A first responder's request for a benefit review conference
must be accelerated by the division and given priority in accordance
with Labor Code §504.055. The first responder must provide notice
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