| (I) If the medical fee dispute involves medical necessity
issues, the insurance carrier shall attach a copy of documentation
that supports an adverse determination in accordance with §19.2005
of this title (relating to General Standards of Utilization Review).
(e) Withdrawal. The requestor may withdraw its request
for MFDR by notifying the division prior to a decision.
(f) MFDR Action. The division will review the completed
request and response to determine appropriate MFDR action.
(1) Request for Additional Information. The division
may request additional information from either party to review the
medical fee issues in dispute. The additional information must be
received by the division no later than 14 days after receipt of this
request. If the division does not receive the requested additional
information within 14 days after receipt of the request, then the
division may base its decision on the information available. The party
providing the additional information shall forward a copy of the additional
information to all other parties at the time it is submitted to the
division.
(2) Issues Raised by the Division. The division may
raise issues in the MFDR process when it determines such an action
to be appropriate to administer the dispute process consistent with
the provisions of the Labor Code and division rules.
(3) Dismissal. A dismissal is not a final decision
by the division. The medical fee dispute may be submitted for review
as a new dispute that is subject to the requirements of this section.
The division may dismiss a request for MFDR if:
(A) the division determines that the medical bills
in the dispute have not been submitted to the insurance carrier for
an appeal, when required;
(B) the request contains an unresolved adverse determination
of medical necessity;
(C) the request contains an unresolved compensability,
extent of injury, or liability dispute for the claim; or
(D) the division determines that good cause exists
to dismiss the request, including a party's failure to comply with
the provisions of this section.
(4) Decision. The division shall send a decision to
the disputing parties or to representatives of record for the parties,
if any, and post the decision on the department's website.
(5) Division Fee. The division may assess a fee in
accordance with §133.305 of this subchapter (relating to MDR--General).
(g) Appeal of MFDR Decision. A party to a medical fee
dispute may seek review of the decision. Parties are deemed to have
received the MFDR decision as provided in §102.5 of this title.
The MFDR decision is final if the request for the benefit review conference
is not timely made. If a party provides the benefit review officer
or administrative law judge with documentation listed in subsection
(d)(2)(H) or (I) of this section that shows unresolved issues regarding
compensability, extent of injury, liability, or medical necessity
for the same service subject to the fee dispute, then the benefit
review officer or administrative law judge shall abate the proceedings
until those issues have been resolved.
(1) A party seeking review of an MFDR decision must
request a benefit review conference no later than 20 days from the
date the MFDR decision is received by the party. The party that requests
a review of the MFDR decision must mediate the dispute in the manner
required by Labor Code, Chapter 410, Subchapter B and request a benefit
review conference under Chapter 141 of this title (relating to Dispute
Resolution--Benefit Review Conference). A party may appear at a benefit
review conference via telephone. The benefit review conference will
be conducted in accordance with Chapter 141 of this title.
(A) Notwithstanding §141.1(b) of this title (relating
to Requesting and Setting a Benefit Review Conference), a seeking
review of an MFDR decision may request a benefit review conference.
(B) At a benefit review conference, the parties to
the dispute may not resolve the dispute by negotiating fees that are
inconsistent with any applicable fee guidelines adopted by the commissioner.
(C) A party must file the request for a benefit review
conference in accordance with Chapter 141 of this title and must include
in the request a copy of the MFDR decision. Providing a copy of the
MFDR decision satisfies the documentation requirements in §141.1(d)
of this title. A first responder's request for a benefit review conference
must be accelerated by the division and given priority in accordance
with Labor Code §504.055. The first responder must provide notice
to the division that the contested case involves a first responder.
(2) If the medical fee dispute remains unresolved after
a benefit review conference, the parties may request arbitration as
provided in Labor Code, Chapter 410, Subchapter C and Chapter 144
of this title (relating to Dispute Resolution). If arbitration is
not elected, the party may appeal the MFDR decision by requesting
a contested case hearing before the State Office of Administrative
Hearings. A first responder's request for arbitration by the division
or a contested case hearing before the State Office of Administrative
Hearings must be accelerated by the division and given priority in
accordance with Labor Code §504.055. The first responder must
provide notice to the division that the contested case involves a
first responder.
(A) To request a contested case hearing before State
Office of Administrative Hearings, a party shall file a written request
for a State Office of Administrative Hearings hearing with the Division's
Chief Clerk of Proceedings not later than 20 days after conclusion
of the benefit review conference in accordance with §148.3 of
this title (relating to Requesting a Hearing).
(B) The party seeking review of the MFDR decision shall
deliver a copy of its written request for a hearing to all other parties
involved in the dispute at the same time the request for hearing is
filed with the division.
(3) A party to a medical fee dispute who has exhausted
all administrative remedies may seek judicial review of the decision
of the Administrative Law Judge at the State Office of Administrative
Hearings. The division and the department are not considered to be
parties to the medical dispute pursuant to Labor Code §413.031(k-2)
and §413.0312(f). Judicial review under this paragraph shall
be conducted in the manner provided for judicial review of contested
cases under Chapter 2001, Subchapter G Government Code, except that
in the case of a medical fee dispute the party seeking judicial review
must file suit not later than the 45th day after the date on which
the State Office of Administrative Hearings mailed the party the notification
of the decision. The mailing date is considered to be the fifth day
after the date the decision was issued by the State Office of Administrative
Hearings. A party seeking judicial review of the decision of the administrative
law judge shall at the time the petition for judicial review is filed
with the district court file a copy of the petition with the division's
chief clerk of proceedings.
(h) Billing of the non-prevailing party. Except as
otherwise provided by Labor Code §413.0312, the non-prevailing
party shall reimburse the division for the costs for services provided
by the State Office of Administrative Hearings and any interest required
by law.
(1) The non-prevailing party shall remit payment to
the division not later than the 30th day after the date of receiving
a bill or statement from the division.
(2) In the event of a dismissal, the party requesting
the hearing, other than the injured employee, shall reimburse the
division for the costs for services provided by the State Office of
Administrative Hearings unless otherwise agreed by the parties.
(3) If the injured employee is the non-prevailing party,
the insurance carrier shall reimburse the division for the costs for
services provided by the State Office of Administrative Hearings.
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| Source Note: The provisions of this §133.307 adopted to be effective December 31, 2006, 31 TexReg 10314; amended to be effective May 25, 2008, 33 TexReg 3954; amended to be effective May 31, 2012, 37 TexReg 3833 |
