| (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 of this title if the dispute involves health care for which the Division has not established a MAR, as applicable. (B) The response shall address only those denial reasons presented to the requestor prior to the date the request for MDR 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 MDR will be dismissed in accordance with subsection (e)(3)(G) or (H) of this section. (C) If the carrier did not receive the provider's disputed billing or the employee's reimbursement request relevant to the dispute prior to the request, the carrier shall include that information in a written statement in the response the carrier submits to the Division. (D) If the medical fee dispute involves compensability, extent of injury, or liability, the carrier shall attach a copy of any related Plain Language Notice in accordance with §124.2 of this title (relating to Carrier Reporting and Notification Requirements). (E) If the medical fee dispute involves medical necessity issues, the carrier shall attach a copy of documentation that supports an adverse determination in accordance with §19.2005 of this title (relating to General Standards of Utilization Review). (3) Provider Response. Upon receipt of the request, the provider shall complete the required sections of the request form and provide any missing information not provided by the requestor and known to the provider. The response shall include: (A) any documentation, including medical bills and employee payment receipts, supporting the reasons why the refund request was denied; (B) a statement of the disputed fee issue(s), which includes a discussion regarding how the submitted documentation supports the provider's position for each disputed fee issue; and (C) a copy of the provider's refund payment, if applicable. (e) MDR Action. The Division will review the completed request and response to determine appropriate MDR 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 Division shall forward any additional information received to the parties. (2) Issues Raised by the Division. The Division may raise issues in the MDR 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. The Division may dismiss a request for medical fee dispute resolution if: (A) the requestor informs the Division, or the Division otherwise determines, that the dispute no longer exists; (B) the requestor is not a proper party to the dispute pursuant to subsection (b) of this section; (C) the Division determines that the medical bills in the dispute have not been submitted to the carrier for reconsideration; (D) the fee disputes for the date(s) of health care in question have been previously adjudicated by the Division; (E) the request for medical fee dispute resolution is untimely; (F) the Division determines the medical fee dispute is for health care services provided pursuant to a private contractual fee arrangement; (G) the request contains an unresolved adverse determination of medical necessity, the Division shall notify the parties of the review requirements pursuant to §133.308 of this subchapter (relating to MDR by Independent Review Organizations) and will dismiss the request in accordance with the process outlined in §133.305 of this subchapter (relating to MDR--General); (H) the carrier has raised a dispute pertaining to compensability, extent of injury, or liability for the claim, the Division shall notify the parties of the review requirements pursuant to §124.2 of this title, and will dismiss the request until those disputes have been resolved by a final decision, inclusive of all appeals; (I) the request for medical fee dispute resolution was not submitted in compliance with the provisions of the Labor Code and this chapter; or (J) the Division determines that good cause exists to dismiss the request. (4) Decision. The Division shall send a decision to the disputing parties and to representatives of record for the parties and post the decision on the Department Internet website. (5) Division Fee. The Division may assess a fee in accordance with §133.305 of this subchapter. (f) Appeal. A party to a medical fee dispute may seek judicial review of the decision by filing a petition in a Travis County district court not later than the 30th day after the date on which the decision is received by the appealing party. The parties will be deemed to have received the decision on the acknowledgement date as defined in §102.5 of this title. Any decision that is not timely appealed becomes final. If a party to a medical fee dispute files a petition for judicial review of the MDR Section decision, the party shall, at the time the petition is filed with the district court, send a copy of the petition for judicial review to the Division. The Division and the Department are not considered to be parties to the medical dispute pursuant to Labor Code §413.031(k). The following information must be included in the petition or provided by cover letter: (1) the MDR Section tracking number for the dispute being appealed; (2) the names of the parties; (3) the cause number; (4) the identity of the court; and (5) the date the petition was filed with the court. (g) Record for Appeal. The Division shall upon receipt of the court petition prepare a record of the MDR Section review and submit a copy of the record to the district court. The Division shall assess the party seeking judicial review expenses incurred by the Division in preparing and copying the record. The record shall contain: (1) the MDR Section decision; (2) the request for MDR; (3) all documentation and written information submitted by the requestor; (4) all documentation and written information submitted by the respondent; (5) other documents contained in the MDR Section files (e.g. correspondence, orders for production); (6) copies of any pertinent medical literature or other documentation utilized to support the decision or, where such documentation is subject to copyright protection or is voluminous, then a listing of such documentation referencing the portion(s) of each document utilized; (7) if not specified in the decision, citations to the particular provisions in statutes, rules, and other authorities that are utilized to support the decision; and (8) signed and certified custodian of records affidavit; (h) Letter of Clerical Correction. Upon receipt of a Division decision, either party may request a clerical correction of an error in a decision. Clerical errors are non-substantive and include but are not limited to typographical or mathematical calculation errors. Only the Division can determine if a clerical correction is required. A request for clerical correction does not alter the deadlines for appeal. |
