| (a) The health care provider must submit all medical
bills to the insurance carrier except when billing the employer in
accordance with subsection (j) of this section.
(b) Except as provided in Labor Code §408.0272(b),
(c), or (d), a health care provider must not submit a medical bill
later than the 95th day after the date the services are provided.
(1) If a designated doctor refers an injured employee
for additional testing or evaluation under §127.10 of this title,
the 95-day period for timely submission of the bill begins on the
date of service of the additional testing or evaluation.
(2) In accordance with subsection (c) of the statute,
the health care provider must submit the medical bill to the correct
workers' compensation insurance carrier no later than the 95th day
after the date the health care provider is notified of the health
care provider's erroneous submission of the medical bill.
(3) A health care provider who submits a medical bill
to the correct workers' compensation insurance carrier must include
a copy of the original medical bill submitted, a copy of the explanation
of benefits (EOB) if available, and sufficient documentation to support
why one or more of the exceptions for untimely submission of a medical
bill under §408.0272 should be applied. The medical bill submitted
by the health care provider to the correct workers' compensation insurance
carrier is subject to the billing, review, and dispute processes established
by Chapter 133, including §133.307(c)(2)(A) - (H) of this title
(relating to MDR of Fee Disputes), which establishes the generally
acceptable standards for documentation.
(c) A health care provider must include correct billing
codes from the applicable division fee guidelines in effect on the
date or dates of service when submitting medical bills.
(d) The health care provider that provided the health
care must submit its own bill, unless:
(1) the health care was provided as part of a return-to-work
rehabilitation program in accordance with the division fee guidelines
in effect for the dates of service;
(2) the health care was provided by an unlicensed individual
under the direct supervision of a licensed health care provider, in
which case the supervising health care provider must submit the bill;
(3) the health care provider contracts with an agent
for purposes of medical bill processing, in which case the health
care provider agent may submit the bill; or
(4) the health care provider is a pharmacy that has
contracted with a pharmacy processing agent for purposes of medical
bill processing, in which case the pharmacy processing agent may submit
the bill.
(e) A medical bill must be submitted:
(1) for an amount that does not exceed the health care
provider's usual and customary charge for the health care provided
in accordance with Labor Code §§413.011 and 415.005; and
(2) in the name of the licensed health care provider
that provided the health care or that provided direct supervision
of an unlicensed individual who provided the health care.
(f) Health care providers must not resubmit medical
bills to insurance carriers after the insurance carrier has taken
final action on a complete medical bill and provided an EOB except
in accordance with §133.250 of this chapter (relating to Reconsideration
for Payment of Medical Bills).
(g) Health care providers may correct and resubmit
as a new bill an incomplete bill that has been returned by the insurance
carrier.
(h) Not later than the 15th day after receipt of a
request for additional medical documentation, a health care provider
must submit to the insurance carrier:
(1) any requested additional medical documentation
related to the charges for health care rendered; or
(2) a notice the health care provider does not possess
requested medical documentation.
(i) The health care provider must indicate on the medical
bill if documentation is submitted related to the medical bill.
(j) The health care provider may elect to bill the
injured employee's employer if the employer has indicated a willingness
to pay the medical bill or bills. Such billing is subject to the following:
(1) A health care provider who elects to submit medical
bills to an employer waives, for the duration of the election period,
the rights to:
(A) prompt payment, as provided by Labor Code §408.027;
(B) interest for delayed payment as provided by Labor
Code §413.019; and
(C) medical dispute resolution as provided by Labor
Code §413.031.
(2) When a health care provider bills the employer,
the health care provider must submit an information copy of the bill
to the insurance carrier, which clearly indicates that the information
copy is not a request for payment from the insurance carrier.
(3) When a health care provider bills the employer,
the health care provider must bill in accordance with the division's
fee guidelines and §133.10 of this chapter (relating to Required
Billing Forms/Formats).
(4) A health care provider must not submit a medical
bill to an employer for charges an insurance carrier has reduced,
denied, or disputed.
(k) A health care provider must not submit a medical
bill to an injured employee for all or part of the charge for any
of the health care provided, except as an informational copy clearly
indicated on the bill, or in accordance with subsection (l) of this
section. The information copy must not request payment.
(l) The health care provider may only submit a bill
for payment to the injured employee in accordance with:
(1) Labor Code §413.042;
(2) Insurance Code §1305.451; or
(3) §134.504 of this title (relating to Pharmaceutical
Expenses Incurred by the Injured Employee).
(m) A designated doctor must include the assignment
number on the medical bill in accordance with §133.10 of this
title (relating to Required Billing Forms/Formats).
(n) A designated doctor who refers the injured employee
for additional testing or evaluation under §127.10 must provide
the assignment number to the health care provider performing the testing
or evaluation. The health care provider performing the testing or
evaluation must include the assignment number on the medical bill
in accordance with §133.10.
(o) This section is effective for medical bills submitted
on or after June 1, 2024, including medical bills submitted as a result
of an examination that was ordered or referred as the result of an
order issued on or after June 1, 2024.
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| Source Note: The provisions of this §133.20 adopted to be effective May 2, 2006, 31 TexReg 3544; amended to be effective January 29, 2009, 34 TexReg 430; amended to be effective June 1, 2024, 49 TexReg 1478 |
