(a)Medical reimbursement for health care services provided to injured employees subject to a workers' compensation health care network established under Insurance Code Chapter 1305 shall be made in accordance with the provisions of Insurance Code Chapter 1305, except as provided in subsections [subsection] (b) and (c) of this section. (b)Examinations conducted pursuant to Labor Code §§408.004, 408.0041, and 408.151 shall be reimbursed in accordance with §134.204 of this chapter (relating to Medical Fee Guideline for Workers' Compensation Specific Services) [§134.202 of this chapter (relating to Medical Fee Guideline)]. (c)Examinations conducted pursuant to Labor Code §408.0042 shall be reimbursed in accordance with §126.14 of this title (relating to Treating Doctor Examination to Define the Compensable Injury). (d)[(c)] Medical reimbursement for health care not provided through a workers' compensation health care network shall be made in accordance with: (1)the Division's fee guidelines; (2)a negotiated contract; or (3)in the absence of an applicable fee guideline or a negotiated contract, a fair and reasonable reimbursement amount as specified in subsection (e) [(d)] of this section [in the absence of an applicable fee guideline]. (e)[(d)] Fair and reasonable reimbursement shall: (1)be [is] consistent with the criteria of Labor Code §413.011; (2)ensure [ensures] that similar procedures provided in similar circumstances receive similar reimbursement; and (3)be [is] based on nationally recognized published studies, published Division medical dispute decisions, and values assigned for services involving similar work and resource commitments, if available. (f)[(e)] The insurance carrier shall consistently apply fair and reasonable reimbursement amounts and maintain, in reproducible format, documentation of the insurance carrier's methodology(ies) establishing fair and reasonable reimbursement amounts. Upon request of the Division, an insurance carrier shall provide copies of such documentation.
This agency hereby certifies that the proposal has
been reviewed by legal counsel and found to be within the agency's
legal authority to adopt.
Filed with the Office
of the Secretary of State on September 21, 2007
TRD-200704413 Norma Garcia
General Counsel
Texas Department of Insurance, Division of Workers'
Compensation
Commission
Earliest possible date of adoption: November 4, 2007
For further information, please call: (512) 804-4715
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