| (F) The additional documentation shall be received by the division
within 14 days of the requestor's receipt of notice pursuant to this rule.
(4) If the respondent is a carrier, the commission shall forward
a copy of the additional documentation to the carrier. The commission shall
deem the carrier to have received the documentation on the acknowledgment
date as defined in §133.1 of this title. If the division forwards the
documentation to the carrier via its Austin representative, the representative
shall sign for the request.
(5) If the respondent is a provider, the commission shall forward
a copy of the request to the provider by regular U.S. mail service or by transmission
of facsimile. The commission shall deem the provider to have received the
request on the acknowledgment date as defined in §133.1 of this title.
(h) Response. The respondent shall file the response to the
requestor's additional documentation for the medical fee dispute, with the
division and the requestor.
(i) Timeliness of Response. A respondent who fails to timely
file a response waives the right to respond. The commission shall deem a response
to be filed on the date the division receives a response. If the respondent
does not respond timely, the commission shall issue a decision based on the
request. The response will be considered timely if received by the commission
within 14 days after the date the respondent received the copy of the requestor's
additional documentation.
(j) Complete Response. All responses to requestor's additional
documentation shall be made on the form and in the manner prescribed by the
commission.
(1) Each response shall be legible, include only a single copy
of each document, and, unless previously provided in the initial request and
requestor's additional documentation, shall include:
(A) documentation of carrier response to reconsideration in
accordance with commission rules;
(B) a copy of all medical bill(s) relevant to the dispute,
if different from that as originally submitted to the carrier for reimbursement;
(C) a copy of all medical audit summaries and/or explanations
of benefits (EOBs) relevant to the fee dispute, or a statement certifying
that the carrier did not receive the provider's disputed billing prior to
the initial request;
(D) a copy of any pertinent medical records or other documents
relevant to the fee dispute;
(E) a statement of the disputed fee issue(s), which includes:
(i) a description of the health care in dispute;
(ii) a statement of the reasons that the disputed medical fees
should not be paid or refunded;
(iii) a discussion of how the Texas Labor Code and commission
rules, including fee guidelines, impact the disputed fee issues; and
(iv) a discussion regarding how the submitted documentation
supports the respondent position for each disputed fee issue; and
(F) if the dispute involves health care for which the commission
has not established a maximum allowable reimbursement, documentation that
discusses, demonstrates, and justifies that the amount the respondent paid
is a fair and reasonable rate of reimbursement in accordance with Texas Labor
Code §413.011 and §§133.1 and 134.1 of this title.
(G) Prior to submission, any documentation that contains confidential
information regarding a person other than the injured employee for that claim
or a party in the dispute, must be redacted by the party submitting the documentation,
to protect the confidential information and the privacy of the individual.
Unredacted information or evidence shall not be considered in resolving the
medical fee dispute.
(2) The response shall address only those denial reasons presented
to the requestor prior to the date the initial request for medical dispute
resolution was filed with the division and the other party. Responses shall
not address new or additional denial reasons or defenses after the filing
of an initial request. Any new denial reasons or defenses raised shall not
be considered in the review.
(k) Filing of Response. The respondent shall file a copy of
the response with the division and the requestor within 14 days of receipt
of the requestor's additional documentation.
(l) Additional Information. The commission may request other
additional information from either party to review the medical fee issues
in dispute. The other additional information shall be received by the division
within 14 days of receipt of this request.
(m) Dismissal. A dismissal does not constitute a decision.
The commission may dismiss a request for medical fee dispute resolution if:
(1) the requestor informs the commission, or the commission
otherwise determines, that the dispute no longer exists;
(2) the individual or entity requesting medical fee dispute
resolution is not a proper party to the dispute per subsection (b) of this
section;
(3) the commission determines that the medical bills in the
dispute have not been properly submitted to the carrier pursuant to §133.304;
(4) the fee disputes for the date(s) of health care in dispute
have been previously adjudicated by the commission; or
(5) the commission determines that good cause exists to dismiss
the request.
(n) Decision. The commission shall send the commission decision
to the parties to the dispute and post the decision on the commission Internet
website after confidential information has been redacted.
(o) Fee. The commission may assess a separate fee in accordance
with Texas Labor Code §413.020 of this title (relating to Commission
Charges).
(p) Appeal. A party to a medical fee dispute may appeal the
commission decision by filing a written request for a State Office of Administrative
Hearings (SOAH) hearing with the Chief Clerk of Proceedings, Division of Hearings
in accordance with §148.3 of this title (relating to Requesting a Hearing).
(1) the appeal must be filed no later than 20 days from the
date the party received the commission decision. The date of receipt of the
decision shall be the acknowledgment date as defined in §133.1 of this
title. The carrier representative shall sign for the decision.
(2) the party appealing the commission decision shall deliver
a copy of its written request for a SOAH hearing to all other parties involved
in the dispute.
(3) a party who has exhausted the party's administrative remedies
under this subtitle and who is aggrieved by a final decision of the SOAH may
seek judicial review of that decision. Judicial review under this subsection
shall be conducted in the manner provided for judicial review of contested
cases under Subchapter G, Chapter 2001, Government Code.
(4) the commission shall post the SOAH decision on the commission
Internet website after confidential information has been redacted.
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