| (a) Applicability. This section applies only to subclaims
by a health care insurer based on information received under Labor
Code §402.084(c-3).
(b) Health care insurer. "Health care insurer" means
an insurance carrier and an authorized representative of an insurance
carrier, as described by Labor Code §402.084(c-1).
(c) Request to Workers' Compensation Insurance Carrier.
A health care insurer seeking reimbursement must first file a reimbursement
request with the workers' compensation insurance carrier.
(1) Form. The request must be in the form/format and
manner prescribed by the Division of Workers' Compensation (Division)
and must contain all the required elements listed on the form.
(2) Notice. The health care insurer must give notice
of the request to the injured employee and the health care provider
that performed the services that are the subject of the reimbursement
request. The notice shall include a copy of the reimbursement request
and an explanation that the health care insurer is seeking reimbursement
for medical care costs.
(d) Deadlines for Response to Reimbursement Request
to the Workers' Compensation Insurance Carrier.
(1) 90 Day Response Deadline. The workers' compensation
insurance carrier must respond to a reimbursement request under this
section by either paying, reducing, or denying payment in writing
not later than the 90th day after the date the reimbursement request
was first received, unless additional information is requested, pursuant
to paragraph (2) of this subsection.
(2) Request for Additional Information. The workers'
compensation insurance carrier may request additional information
from the health care insurer if there is not sufficient information
to substantiate the claim. The health care insurer has 30 days after
receiving the request for more information to provide the information
requested to the workers' compensation insurance carrier. Any request
for additional information shall be in writing, be relevant and necessary
for the resolution of the request. A workers' compensation insurance
carrier shall not be penalized, including not being held responsible
for costs of obtaining the additional information, if the workers'
compensation insurance carrier denies payment in order to move to
dispute resolution to obtain additional information to process the
request. It is the health care insurer's obligation to furnish its
authorized representatives with any information necessary for the
resolution of a reimbursement request. The Division considers any
medical billing information or documentation possessed by the health
care insurer or one of its authorized representatives to be simultaneously
possessed by the health care insurer and all of its authorized representatives.
(3) 120 Day Response Deadline. If the workers' compensation
insurance carrier has requested additional information from the health
care insurer pursuant to paragraph (2) of this subsection, the workers'
compensation insurance carrier must respond in writing to the health
care insurer's reimbursement request not later than the 120th day
after the date the reimbursement request was first received, unless
otherwise provided by mutual agreement.
(e) Response to a Reimbursement Request. The workers'
compensation insurance carrier must respond to a reimbursement request
by either paying, reducing or denying payment.
(1) Paying or Reducing Payment.
(A) The workers' compensation insurance carrier shall
pay the health care insurer the lesser of:
(i) the amount payable under the applicable Division
fee guideline as of the date of service; or
(ii) the actual amount paid by the health care insurer.
(B) If No Fee Guideline. In the absence of a Division
fee guideline for a specific service paid, the amount per service
paid by the health care insurer shall be considered in determining
a fair and reasonable payment pursuant to §134.1 of this title
(relating to Medical Reimbursement).
(C) Interest. The health care insurer may not recover
interest as a part of the payable amount.
(D) Previous Payments. The workers' compensation insurance
carrier shall reduce any reimbursable amount by any payments the workers'
compensation insurance carrier previously made to the same health
care provider for the provision of the same health care on the same
dates of service. In making such a reduction in reimbursement, the
workers' compensation insurance carrier shall provide evidence of
the previous payments made to the health care provider.
(E) Notice to Injured Employee and Health Care Provider.
The workers' compensation insurance carrier must give notice of its
response to the reimbursement request to the injured employee and
the health care provider that performed the services that are the
subject of the reimbursement request. If the claim is compensable,
the notice shall include an explanation that the claim is compensable
and that the health care provider must reimburse the injured employee
for any amounts paid to the health care provider by the injured employee.
(F) The health care provider may submit a reimbursement
request to the workers' compensation insurance carrier for any money
owed under Division fee guidelines for the medical services rendered
on a compensable claim and is entitled to dispute resolution under §133.307
of this title (relating to MDR of Fee Disputes). The workers' compensation
insurance carrier is liable for full payment in accordance with Division
fee guidelines and applicable rules for the medical services rendered
on a compensable claim.
(2) Explanation of Benefits. The workers' compensation
insurance carrier must provide the health care insurer, all health
care providers, and the injured employee an explanation of benefits
(EOB) in the form and manner prescribed by the Division. The EOB must
provide sufficient explanation regarding the basis for a denial of
the reimbursement request.
(f) Reimbursement of Injured Employee. If the injured
employee's medical care costs are reimbursable under Title 5 of the
Labor Code, a health care provider must refund to the injured employee
any payments made by the injured employee to the health care provider,
including but not limited to, copays and deductibles. Reimbursement
must be made within 45 days of receipt of the notice that the claim
is compensable.
(g) Filing Notice of Subclaimant Status.
(1) 120 Day Deadline. A health care insurer must file
a written notice of subclaimant status with the Division not later
than the 120th day after a workers' compensation insurance carrier
fails to respond to a health care insurer's reimbursement request
or reduces or denies the requested reimbursement amount.
(2) Location for Filing Notice. The notice may be filed
with the Division of Workers' Compensation at any local Division field
office or at the Division's central office in Austin, Texas.
(3) One Injured Employee Per Notice. A health care
insurer must file separate notices for each individual injured employee
in which the health care insurer seeks subclaimant status.
(4) One Notice Per Injured Employee Date of Injury.
If an individual injured employee has multiple claims based on different
dates of injury, the health care insurer must file a separate notice
for each date of injury for which medical benefits were provided.
(5) Form. The notice of subclaimant status must be
in the form and manner prescribed by the Division.
(h) Request for Dispute Resolution. The rules applicable
to dispute resolution vary according to the reason for denial of reimbursement.
Disputes regarding extent of injury, liability, or medical necessity
must be resolved prior to pursuing a medical fee dispute. A request
for medical dispute resolution may be filed in lieu of a request for
subclaimant status, and shall be considered a request for subclaimant
status for purposes of this section.
(1) Claim or Treatment Not Compensable.
(A) A health care insurer must file a request for a
benefit review conference pursuant to §141.1 of this title (relating
to Requesting and Setting a Benefit Review Conference) with the Division
not later than the 120th day after a workers' compensation insurance
carrier reduces or denies the requested reimbursement amount based
on compensability or extent of injury issues.
(B) The health care insurer may pursue dispute resolution
to obtain an order from an administrative law judge regarding compensability
or eligibility for benefits in accordance with Labor Code Chapter
410 and applicable Division rules.
(C) A subclaim dispute based on a denial of reimbursement
due to compensability or extent of injury is subject to dispute resolution
pursuant to Chapters 140 - 143 of this title (relating to Dispute
Resolution).
(2) Lack of Medical Necessity.
Cont'd... |
