| (k) Health care providers, injured employees, employers,
attorneys, and other participants in the system shall not resubmit
medical bills to insurance carriers after the insurance carrier has
taken final action on a complete medical bill and provide an explanation
of benefits except as provided in §133.250 and Chapter 133, Subchapter
D of this title.
(l) All payments of medical bills that an insurance
carrier makes on or after the 60th day after the date the insurance
carrier originally received the complete medical bill shall include
interest calculated in accordance with §134.130 of this title
without any action taken by the division. The interest payment shall
be paid at the same time as the medical bill payment.
(m) Except as provided by Insurance Code §1305.153,
when an insurance carrier remits payment to a health care provider
agent, the agent shall remit to the health care provider the full
amount that the insurance carrier reimburses. If the insurance carrier
remits payment under Insurance Code §1305.153, then the payment
must be made in accordance with that section.
(n) When an insurance carrier remits payment to a pharmacy
processing agent, the pharmacy processing agent's reimbursement from
the insurance carrier shall be made in accordance with §134.503
of this title. The pharmacy's reimbursement shall be made in accordance
with the terms of its contract with the pharmacy processing agent.
(o) An insurance carrier commits an administrative
violation if the insurance carrier fails to pay, reduce, deny, or
notify the health care provider of the intent to audit a medical bill
in accordance with Labor Code §408.027 and division rules.
(p) For the purposes of this section, all utilization
review must be performed by an insurance carrier that is registered
with or a utilization review agent that is certified by the Texas
Department of Insurance to perform utilization review in accordance
with Insurance Code Chapter 4201 and Chapter 19 of this title.
(1) All utilization review agents or registered insurance
carriers who perform utilization review under this section must comply
with Labor Code §504.055 and any other provisions of Chapter
19, Subchapter U of this title (relating to Utilization Reviews for
Health Care Provided under Workers' Compensation Insurance Coverage)
that relate to the expedited provision of medical benefits to first
responders employed by political subdivisions who sustain a serious
bodily injury in the course and scope of employment.
(2) In accordance with Labor Code §501.028(b),
an insurance carrier must accelerate and give priority to a claim
for medical benefits:
(A) by a member of the Texas military forces who,
(i) while on state active duty,
(ii) sustains a serious bodily injury, as defined by
Penal Code §1.07;
(B) including all health care required to cure or relieve
the effects naturally resulting from a compensable injury.
(q) When denying payment due to an adverse determination
under this section, the insurance carrier shall comply with the requirements
of §19.2009 of this title (relating to Notice of Determinations
Made in Utilization Review). Additionally, in any instance where the
insurance carrier is questioning the medical necessity or appropriateness
of the health care services, the insurance carrier shall comply with
the requirements of §19.2010 if this title (relating to Requirements
Prior to Issuing Adverse Determination), including the requirement
that prior to issuance of an adverse determination the insurance carrier
shall afford the health care provider a reasonable opportunity to
discuss the billed health care with a doctor or, in cases of a dental
plan or chiropractic services, with a dentist or chiropractor, respectively.
|
| Source Note: The provisions of this §133.240 adopted to be effective May 2, 2006, 31 TexReg 3544; amended to be effective July 1, 2012, 37 TexReg 2408; amended to be effective March 30, 2014, 39 TexReg 2095; amended to be effective December 28, 2023, 48 TexReg 7999 |
