| (a) Applicability. The applicability of this section
is as follows.
(1) This section applies to a request to the division
for medical fee dispute resolution (MFDR) as authorized by the Texas
Workers' Compensation Act that is filed on or after June 1, 2012.
Dispute resolution requests filed prior to June 1, 2012, shall be
resolved in accordance with the statutes and rules in effect at the
time the request was filed.
(2) In resolving disputes regarding the amount of payment
due for health care determined to be medically necessary and appropriate
for treatment of a compensable injury, the role of the division is
to adjudicate the payment, given the relevant statutory provisions
and division rules.
(3) In accordance with Labor Code §504.055 a request
for medical fee dispute resolution that involves a first responder's
request for reimbursement of medical expenses paid by the first responder
will be accelerated by the division and given priority. The first
responder shall provide notice to the division that the request involves
a first responder.
(b) Requestors. The following parties may be requestors
in medical fee disputes:
(1) the health care provider, or a qualified pharmacy
processing agent, as described in Labor Code §413.0111, in a
dispute over the reimbursement of a medical bill(s);
(2) the health care provider in a dispute about the
results of a division or insurance carrier audit or review which requires
the health care provider to refund an amount for health care services
previously paid by the insurance carrier;
(3) the injured employee in a dispute involving an
injured employee's request for reimbursement from the insurance carrier
of medical expenses paid by the injured employee;
(4) the injured employee when requesting a refund of
the amount the injured employee paid to the health care provider in
excess of a division fee guideline; or
(5) a subclaimant in accordance with §140.6 of
this title (relating to Subclaimant Status: Establishment, Rights,
and Procedures), §140.7 of this title (relating to Health Care
Insurer Reimbursement under Labor Code §409.0091), or §140.8
of this title (relating to Procedures for Health Care Insurers to
Pursue Reimbursement of Medical Benefits under Labor Code §409.0091),
as applicable.
(c) Requests. Requests for MFDR shall be filed in the
form and manner prescribed by the division. Requestors shall file
two legible copies of the request with the division.
(1) Timeliness. A requestor shall timely file the request
with the division's MFDR Section or waive the right to MFDR. The division
shall deem a request to be filed on the date the MFDR Section receives
the request. A decision by the MFDR Section that a request was not
timely filed is not a dismissal and may be appealed pursuant to subsection
(g) of this section.
(A) A request for MFDR that does not involve issues
identified in subparagraph (B) of this paragraph shall be filed no
later than one year after the date(s) of service in dispute.
(B) A request may be filed later than one year after
the date(s) of service if:
(i) a related compensability, extent of injury, or
liability dispute under Labor Code Chapter 410 has been filed, the
medical fee dispute shall be filed not later than 60 days after the
date the requestor receives the final decision, inclusive of all appeals,
on compensability, extent of injury, or liability;
(ii) a medical dispute regarding medical necessity
has been filed, the medical fee dispute must be filed not later than
60 days after the date the requestor received the final decision on
medical necessity, inclusive of all appeals, related to the health
care in dispute and for which the insurance carrier previously denied
payment based on medical necessity; or
(iii) the dispute relates to a refund notice issued
pursuant to a division audit or review, the medical fee dispute must
be filed not later than 60 days after the date of the receipt of a
refund notice.
(2) Health Care Provider or Pharmacy Processing Agent
Request. The requestor shall provide the following information and
records with the request for MFDR in the form and manner prescribed
by the division. The provider shall file the request with the MFDR
Section by any mail service or personal delivery. The request shall
include:
(A) the name, address, and contact information of the
requestor;
(B) the name of the injured employee;
(C) the date of the injury;
(D) the date(s) of the service(s) in dispute;
(E) the place of service;
(F) the treatment or service code(s) in dispute;
(G) the amount billed by the health care provider for
the treatment(s) or service(s) in dispute;
(H) the amount paid by the workers' compensation insurance
carrier for the treatment(s) or service(s) in dispute;
(I) the disputed amount for each treatment or service
in dispute;
(J) a paper copy of all medical bill(s) related to
the dispute, as originally submitted to the insurance carrier in accordance
with this chapter and a paper copy of all medical bill(s) submitted
to the insurance carrier for an appeal in accordance with §133.250
of this chapter (relating to General Medical Provisions);
(K) a paper copy of each explanation of benefits (EOB)
related to the dispute as originally submitted to the health care
provider in accordance with this chapter or, if no EOB was received,
convincing documentation providing evidence of insurance carrier receipt
of the request for an EOB;
(L) when applicable, a copy of the final decision regarding
compensability, extent of injury, liability and/or medical necessity
for the health care related to the dispute;
(M) a copy of all applicable medical records related
to the dates of service in dispute;
(N) a position statement of the disputed issue(s) that
shall include:
(i) the requestor's reasoning for why the disputed
fees should be paid or refunded,
(ii) how the Labor Code and division rules, including
fee guidelines, impact the disputed fee issues, and
(iii) how the submitted documentation supports the
requestor's position for each disputed fee issue;
(O) documentation that discusses, demonstrates, and
justifies that the payment amount being sought is a fair and reasonable
rate of reimbursement in accordance with §134.1 of this title
(relating to Medical Reimbursement) or §134.503 of this title
(relating to Pharmacy Fee Guideline) when the dispute involves health
care for which the division has not established a maximum allowable
reimbursement (MAR) or reimbursement rate, as applicable;
(P) if the requestor is a pharmacy processing agent,
a signed and dated copy of an agreement between the processing agent
and the pharmacy clearly demonstrating the dates of service covered
by the contract and a clear assignment of the pharmacy's right to
participate in the MFDR process. The pharmacy processing agent may
redact any proprietary information contained within the agreement;
and
(Q) any other documentation that the requestor deems
applicable to the medical fee dispute.
(3) Subclaimant Dispute Request. The requestor shall
provide the appropriate information with the request that is consistent
with the provisions of §140.6 or §140.8 of this title. A
request made by a subclaimant under Labor Code §409.009 shall
comply with §140.6 of this title and submit the documents to
the Division required thereunder. A request made by a subclaimant
under Labor Code §409.0091 shall comply with the document requirements
of §140.8 of this title and submit the documents to the Division
required thereunder.
(4) Injured Employee Dispute Request. An injured employee
who has paid for health care may request MFDR of a refund or reimbursement
request that has been denied. The injured employee's dispute request
shall be sent to the MFDR Section in the form and manner prescribed
by the division by mail service, personal delivery or facsimile and
shall include:
(A) the name, address, and contact information of the
injured employee;
(B) the date of the injury;
(C) the date(s) of the service(s) in dispute;
(D) a description of the services paid;
(E) the amount paid by the injured employee;
(F) the amount of the medical fee in dispute;
(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
Cont'd... |
