| (a) If the health care provider is dissatisfied with
the insurance carrier's final action on a medical bill, the health
care provider may request that the insurance carrier reconsider its
action. If the health care provider is requesting reconsideration
of a bill denied based on an adverse determination, the request for
reconsideration constitutes an appeal for the purposes of §19.2011
of this title (relating to Written Procedures for Appeal of Adverse
Determinations) and may be submitted orally or in writing.
(b) The health care provider shall submit the request
for reconsideration no later than 10 months from the date of service.
(c) A health care provider shall not submit a request
for reconsideration until:
(1) the insurance carrier has taken final action on
a medical bill; or
(2) the health care provider has not received an explanation
of benefits within 50 days from submitting the medical bill to the
insurance carrier.
(d) A written request for reconsideration shall:
(1) reference the original bill and include the same
billing codes, date(s) of service, and dollar amounts as the original
bill;
(2) include a copy of the original explanation of benefits,
if received, or documentation that a request for an explanation of
benefits was submitted to the insurance carrier;
(3) include any necessary and related documentation
not submitted with the original medical bill to support the health
care provider's position; and
(4) include a bill-specific, substantive explanation
in accordance with §133.3 of this title (relating to Communication
Between Health Care Providers and Insurance Carriers) that provides
a rational basis to modify the previous denial or payment.
(e) An oral request for reconsideration must clearly
identify the health care services(s) denied based on an adverse determination
and include a substantive explanation in accordance with §133.3
of this title that provides a rational basis to modify the previous
denial or payment. Not later than the fifth working day after the
date of receipt of the request for reconsideration, the insurance
carrier must send to the requesting party a letter acknowledging the
date of the receipt of the oral request that includes a reasonable
list of documents the requesting party is required to submit. This
subsection applies to reconsideration requests made on or after six
months from the effective date of this rule.
(f) An insurance carrier shall review all written reconsideration
requests for completeness in accordance with subsection (d) of this
section and may return an incomplete written reconsideration request
no later than seven days from the date of receipt. A health care provider
may complete and resubmit its written request to the insurance carrier.
(g) The insurance carrier shall take final action on
a reconsideration request within 30 days of receiving the request
for reconsideration. The insurance carrier shall provide an explanation
of benefits:
(1) in accordance with §133.240(e) - (f) of this
title (relating to Medical Payments and Denial) for all items included
in a reconsideration request in the form and format prescribed by
the division when there is a change in the original, final action;
or
(2) in accordance with §133.240(e)(1) and §133.240(f)
of this title when there is no change in the original, final action.
(h) A health care provider shall not resubmit a request
for reconsideration earlier than 35 days from the date the insurance
carrier received the original request for reconsideration or after
the insurance carrier has taken final action on the reconsideration
request.
(i) If the health care provider is dissatisfied with
the insurance carrier's final action on a medical bill after reconsideration,
the health care provider may request medical dispute resolution in
accordance with the provisions of Chapter 133, Subchapter D of this
title (relating to Dispute of Medical Bills).
(j) 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.
(k) 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 of this title (relating to Requirements Prior to
Adverse Determination) and §19.2011 of this title, including
the requirement that prior to issuance of an adverse determination
on the request for reconsideration 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 §133.250 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 |
