| (a) Applicability. This rule applies to a request for medical fee dispute resolution for which the dispute resolution request was filed on or after January 1, 2003. Dispute resolution requests filed prior to January 1, 2003 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 with 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 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 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) Request (General). All provider and carrier requests for medical dispute resolution shall be made in the form, format, and manner prescribed by the commission. (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) The requestor shall file two copies of the request with the division by any mail service or personal delivery. (A) when the respondent is an insurance carrier, the division shall forward a copy of the request to the insurance carrier. The division shall deem the insurance carrier to have received the request on the acknowledgement date as defined in §133.1 of this title (relating to Definitions for Chapter 133, Benefits-Medical Benefits). If the division forwards the request to the insurance carrier via its Austin representative, the representative shall sign for the request. (B) when the respondent is a health care provider, the division shall forward a copy of the request to the health care provider by a verifiable means of delivery. The division shall deem the health care provider to have received the request on the acknowledgement date as defined in §133.1 of this title. (2) Each copy of the 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. (3) Upon receipt of the 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 request; and (C) file the completed request with the division and the requestor within fourteen (14) calendar days of respondent's receipt of the request. (4) If the dispute has already been resolved, the respondent shall certify this on the form. If the respondent did not receive the provider's disputed billing or the employee's reimbursement request relevant to the dispute prior to the request, the respondent shall include certification of this when the respondent files the request form with the division. If dispute has not been resolved and involves compensability/extent of injury, the respondent shall attach any related TWCC-21s in accordance with §124.2 of this title. (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 request shall be filed with the division in the form, format, and manner prescribed by the commission. The requestor shall submit two copies of the request to the division by any mail service or personal delivery and the division will forward one copy of the request to the insurance carrier via its Austin representative, the representative shall sign for the request. The 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 Cont'd... |
