| (a) Applicability. This rule applies to a request for medical
fee dispute resolution for which the initial dispute resolution request was
filed on or after January 1, 2002. Dispute resolution requests filed prior
to January 1, 2002 shall be resolved in accordance with the rules in effect
at the time the request was filed. In resolving disputes over 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 commission is to adjudicate
the payment, given the relevant statutory provisions and commission rules.
Medical necessity is not an issue in a medical fee dispute.
(b) Parties. The following persons may be requestors and respondents
in medical fee disputes:
(1) the health care provider (provider) and the insurance carrier
(carrier) in a dispute of a medical bill;
(2) the injured employee (employee) and the carrier in a dispute
involving an employee's request for reimbursement of medical expenses;
(3) the carrier and the provider in a dispute involving a carrier's
refund request;
(4) the provider and the commission in a dispute involving
a commission refund order issued pursuant to an audit or review.
(c) Requests. A request for medical dispute resolution of a
medical fee dispute must be timely filed simultaneously with the carrier and
the commission's Medical Review Division (division).
(d) Timeliness. A person or entity who fails to timely file
a request waives the right to medical dispute resolution. The commission shall
deem a request to be filed on the date the division receives the initial request,
and timeliness shall be determined as follows:
(1) A request for medical dispute resolution on a carrier denial
or reduction, of a medical bill pursuant to §133.304 of this title (relating
to Medical Payments and Denials) or an employee reimbursement request shall
be considered timely if it is filed with the carrier and the division no later
than one (1) year after the date(s) of service in dispute.
(2) A request for medical dispute resolution on a provider
denial or reduction of a carrier request for refund of payment for health
care shall be considered timely if it is filed with the division pursuant
to the provisions in §133.304 and no later than one (1) year from the
date(s) of service in dispute.
(3) A request for medical dispute resolution on a commission
refund order issued pursuant to a commission audit or review shall be considered
timely if a request for a hearing is filed with the commission Chief Clerk
of Proceedings, Hearing Division, not later than 20 days after the date of
receipt of the refund order.
(e) Initial Request (General). All provider and carrier requests
for medical dispute resolution shall be made in the form, format, and manner
prescribed by the commission. (Initial requests for medical dispute resolution
on medical fee disputes involving an employee's request for reimbursement
of medical expenses are governed by subsection (f) of this section).
(1) Each initial request shall be legible, include only a single
copy of each document, and shall include:
(A) a copy of all medical bill(s) as originally submitted to
the carrier for reconsideration in accordance with §133.304;
(B) a copy of each explanation of benefits (EOB) or response
to the refund request relevant to the fee dispute or, if no EOB was received,
convincing evidence of carrier receipt of the provider request for an EOB;
(C) a table listing the specific disputed health care and charges
in the form, format, and manner prescribed by the commission; and
(D) if the carrier has raised a dispute pertaining to liability
for the claim, compensability, or extent of injury, in accordance with §124.2
of this title (relating to Carrier Reporting and Notification Requirements),
the request for an IRO will be held in abeyance until those disputes have
been resolved by a final decision of the commission.
(2) Upon receipt of the initial request, the respondent shall:
(A) complete the remaining sections of the request form other
than information for an IRO review pursuant to the requirements under §133.308;
(B) provide any missing information required on the form, including
absent EOBs not submitted by the requestor with the initial request; and
(C) file the completed request with the division and the requestor
within three (3) working days of respondent's receipt of the initial request.
(3) If the respondent did not receive the provider's disputed
billing or the employee's reimbursement request relevant to the dispute prior
to the initial request, or if the dispute has already been resolved, the respondent
shall certify this on the form.
(f) Employee Reimbursement Dispute. An employee who has paid
for health care may request medical dispute resolution of a denied reimbursement.
The employee may only pursue reimbursement up to the amount the employee paid
the provider. Reimbursement shall be fair and reasonable in accordance with
commission rules, and shall not exceed the Maximum Allowable Reimbursement
(MAR) as established in the appropriate fee guideline, or in the absence of
a fee guideline, the amount determined to be fair and reasonable for the health
care. Health care requiring preauthorization or concurrent review pursuant
to §134.600 of this title (relating to Preauthorization, Concurrent Review,
and Voluntary Certification of Health Care) must have received the preauthorization
or concurrent review approval. The employee's initial request shall be made
in the form, format, and manner prescribed by the commission. The initial
request must be legible, must contain only a single copy of each document,
and must include:
(1) an explanation of the disputed fee issue(s);
(2) proof of employee payment for the health care for which
the employee is requesting reimbursement (include receipts of payment made);
and
(3) a copy of any EOB relevant to the dispute, or , if no EOB
was received, convincing evidence of carrier receipt of employee request for
reimbursement.
(g) Commission Notice. The respondent shall file the completed
request with the requestor and with the division by transmission of facsimile.
(1) The commission shall review the completed request to determine
appropriate medical dispute resolution action.
(2) If the request contains unresolved medical necessity issues,
the commission shall notify the parties of the review requirements pursuant
to §133.308.
(3) If the request contains only medical fee disputes, the
commission shall notify the parties and require the requestor to send to the
commission, two copies of additional documentation relevant to the fee dispute.
The additional documentation shall include:
(A) documentation of the request for and response to reconsideration
(when a provider is requesting dispute resolution on a carrier reduction or
denial of a medical bill) or, if the carrier failed to respond to the request
for reconsideration, convincing evidence of the carrier's receipt of that
request;
(B) a copy of any pertinent medical records or other documents
relevant to the fee dispute;
(C) a statement of the disputed issue(s) that shall include:
(i) a description of the health care for which payment is in
dispute,
(ii) the requestor's reasoning for why the disputed fees should
be paid or refunded,
(iii) how the Texas Labor Code and commission rules, and fee
guidelines, impact the disputed fee issues, and
(iv) how the submitted documentation supports the requestor
position for each disputed fee issue;
(D) 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 payment amount being sought
is a fair and reasonable rate of reimbursement in accordance with §133.1
of this title (relating to Definitions) and §134.1 of this title (relating
to Use of the Fee Guidelines);
(E) 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.
Cont'd... |
