| (a) Applicability. This section applies to a request
to the division for medical fee dispute resolution (MFDR) as authorized
by the Texas Workers' Compensation Act.
(1) Dispute resolution requests must 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.
(4) The 2020 amendments regarding electronic submission
of dispute requests are effective February 22, 2021.
(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 must be legible and
filed in the form and manner prescribed by the division.
(1) Timeliness. A requestor must timely file the request
with the division or waive the right to MFDR. The division will deem
a request to be filed on the date the division receives the request.
A decision by the division 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 must send the request to the division in the
form and manner prescribed by the division by any mail service, personal
delivery, or electronic transmission as described in §102.5 of
this title. The request must 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 copy of all medical bills related to the dispute,
as described in §133.10 of this chapter (concerning Required
Billing Forms/Formats) or §133.500 (concerning Electronic Formats
for Electronic Medical Bill Processing) as originally submitted to
the insurance carrier in accordance with this chapter, and a copy
of all medical bills submitted to the insurance carrier for an appeal
in accordance with §133.250 of this chapter (concerning Reconsideration
for Payment of Medical Bills);
(K) each explanation of benefits or e-remittance (collectively
"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.
(A) A request made by a subclaimant under Labor Code §409.009
(relating to Subclaims) must comply with §140.6 of this title
(concerning Subclaimant Status: Establishment, Rights, and Procedures)
and submit the required documents to the division.
(B) A request made by a subclaimant under Labor Code §409.0091
(relating to Reimbursement Procedures for Certain Entities) must comply
with the document requirements of §140.8 of this title (concerning
Procedures for Health Care Insurers to Pursue Reimbursement of Medical
Benefits under Labor Code §409.0091) and submit the required
documents to the division.
(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 must send the request
to the division in the form and manner prescribed by the division
by mail service, personal delivery, or electronic transmission as
described in §102.5 of this title and must 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
(I) a copy of the insurance carrier's or health care
provider's denial of reimbursement or refund relevant to the dispute,
or if no denial was received, convincing evidence of the injured employee's
attempt to obtain reimbursement or refund from the insurance carrier
or health care provider.
(5) Division Response to Request. The division will
forward a copy of the request and the documentation submitted in accordance
with paragraph (2), (3), or (4) of this subsection to the respondent.
The respondent shall be deemed to have received the request on the
acknowledgment date as defined in §102.5 of this title (relating
to General Rules for Written Communications to and from the Commission).
(d) Responses. Responses to a request for MFDR must
be legible and submitted to the division and to the requestor in the
form and manner prescribed by the division.
(1) Timeliness. The response will be deemed timely
if received by the division through mail service, personal delivery,
or electronic transmission, as described in §102.5 of this title,
within 14 calendar days after the date the respondent received the
copy of the requestor's dispute. If the division does not receive
the response information within 14 calendar days of the dispute notification,
then the division may base its decision on the available information.
(2) Response. On receipt of the request, the respondent
must provide any missing information not provided by the requestor
and known to the respondent. The respondent must also provide the
following information and records:
(A) the name, address, and contact information of the
respondent;
(B) all initial and appeal EOBs related to the dispute
as originally submitted to the health care provider in accordance
with this chapter, related to the health care in dispute not submitted
by the requester, or a statement certifying that the respondent did
not receive the health care provider's disputed billing before the
dispute request;
(C) all medical bill(s) related to the dispute, submitted
in accordance with this chapter if different from that originally
submitted to the insurance carrier for reimbursement;
(D) any pertinent medical records or other documents
relevant to the fee dispute not already provided by the requestor;
(E) a statement of the disputed fee issue(s), which
includes:
(i) a description of the health care in dispute;
(ii) a position statement of reasons why the disputed
medical fees should not be paid;
(iii) a discussion of how the Labor Code and division
rules, including fee guidelines, impact the disputed fee issues;
(iv) a discussion regarding how the submitted documentation
supports the respondent's position for each disputed fee issues;
(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
or §134.503 of this title if the dispute involves health care
for which the division has not established a MAR or reimbursement
rate, as applicable.
(F) The responses shall address only those denial reasons
presented to the requestor prior to the date the request for MFDR
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 MFDR will be dismissed in accordance
with subsection (f)(3)(B) or (C) of this section.
(G) If the respondent did not receive the health care
provider's disputed billing or the employee's reimbursement request
relevant to the dispute prior to the request, the respondent shall
include that information in a written statement.
(H) If the medical fee dispute involves compensability,
extent of injury, or liability, the insurance carrier must attach
any related Plain Language Notice in accordance with §124.2 of
this title (concerning Insurance Carrier Reporting and Notification
Requirements).
Cont'd... |
