(I)[(E)] 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). [(3)Provider Response. Upon receipt of the request, the provider shall complete the required sections of the request form and provide any missing information not provided by the requestor and known to the provider. The response shall include:] [(A)any documentation, including medical bills, in a paper billing format using an appropriate DWC approved billing format, and employee payment receipts, supporting the reasons why the refund request was denied;] [(B)a statement of the disputed fee issue(s), which includes a discussion regarding how the submitted documentation supports the provider's position for each disputed fee issue; and] [(C)a copy of the provider's refund payment, if applicable.] (e)Withdrawal. The requestor may withdraw its request for MFDR by notifying the division prior to a decision. (f)[(e)] MFDR [MDR] Action. The division [Division] will review the completed request and response to determine appropriate MFDR [ MDR] action. (1)Request for Additional Information. The division [ 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 [Division] no later than 14 days after receipt of this request. If the division [Division] does not receive the requested additional information within 14 days after receipt of the request, then the division [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 [Division]. (2)Issues Raised by the Division. The division [ Division] may raise issues in the MFDR [MDR] 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 [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 [Division] may dismiss a request for MFDR [ medical fee dispute resolution] if: [(A)the requestor informs the Division, or the Division otherwise determines, that the dispute no longer exists;] [(B)the requestor is not a proper party to the dispute pursuant to subsection (b) of this section;] (A)[(C)] the division [ Division] determines that the medical bills in the dispute have not been submitted to the insurance carrier for reconsideration , when required; [(D)the fee disputes for the date(s) of health care in question have been previously adjudicated by the Division;] [(E)the request for medical fee dispute resolution is untimely;] [(F)the Division determines the medical fee dispute is for health care services provided pursuant to a private contractual fee arrangement;] (B)[(G)] the request contains an unresolved adverse determination of medical necessity[, the Division shall notify the parties of the review requirements pursuant to §133.308 of this subchapter (relating to MDR by Independent Review Organizations) and will dismiss the request in accordance with the process outlined in §133.305 of this subchapter (relating to MDR--General)]; (C)[(H)] the request contains an unresolved [carrier has raised a dispute pertaining to] compensability, extent of injury, or liability dispute for the claim[, the Division shall notify the parties of the review requirements pursuant to §124.2 of this title, and will dismiss the request until those disputes have been resolved by a final decision, inclusive of all appeals]; or [(I)the request for medical fee dispute resolution was not submitted in compliance with the provisions of the Labor Code and this chapter; or] (D)[(J)] the division [ 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 [Division] shall send a decision to the disputing parties or [and] to representatives of record for the parties, if any, and post the decision on the department's [Department Internet] website. (5)Division Fee. The division [Division] may assess a fee in accordance with §133.305 of this subchapter. (g)[(f)] Appeal of MFDR Decision [to Contested Case Hearing]. A party to a medical fee dispute may seek review of the [MDR] decision [or dismissal as provided in this subsection]. Parties are deemed to have received the MFDR [MDR] 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. Parties may not raise issues regarding liability, extent, compensability, or medical necessity at a benefit review conference or contested case hearing at the State Office of Administrative Hearings for a medical fee dispute. (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). 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 party to a medical fee dispute 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(a) 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--Arbitration). 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. [(1)A party to a medical fee dispute in which the amount of reimbursement sought by the requestor in its request for MDR is greater than $2000.00, may request a contested case hearing before the State Office of Administrative Hearings (SOAH).] (A)To request a contested case hearing before SOAH, a party shall file a written request for a SOAH 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 [ MDR] 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 [ Division]. [(2)A party to a medical fee dispute in which the amount of reimbursement sought by the requestor in its request for MDR is equal to or less than $2000.00 may request a Division contested case hearing conducted by a Division hearing officer. A benefit review conference is not a prerequisite to a Division contested case hearing under this paragraph.] [(A)To request a Division contested case hearing, a written request for a Division contested case hearing must be filed with the Division's Chief Clerk no later than the later of the 20th day after the effective date of this section or the 20th day after the date on which the decision is received by the appealing party. The request must be filed in compliance with Division rules. The party appealing the 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 a hearing is filed with the Division.] [(B)Requests that are timely submitted to a Division location other than the Division's Chief Clerk, such as a local field office of the Division, will be considered timely filed and forwarded to the Chief Clerk for processing; however this may result in a delay in the processing of the request. Any decision that is not timely appealed becomes final.] [(C)Prior to a Division contested case hearing, either party may request a correction of a clerical error in a decision. Clerical errors are non-substantive and include, but are not limited to, typographical or mathematical calculation errors. Only the Division can determine if a clerical correction is required. A request for a correction of a clerical error does not alter the deadlines for appeal.] [(D)At a Division contested case hearing under this paragraph, parties may not raise issues regarding liability, compensability, or medical necessity at a contested case hearing for a medical fee dispute.] [(E)Except as otherwise provided in this section, a Division contested case hearing shall be conducted in accordance with Chapters 140 and 142 of this title (relating to Dispute Resolution/General Provisions and Benefit Contested Case Hearing).] (3)[(F)] A party to a medical fee dispute who has exhausted all administrative remedies may seek judicial review of the [Division's] 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. [The parties will be deemed to have received the decision as provided in §102.5 of this title. A decision becomes final and appealable when issued by a Division hearing officer. If a party to a medical fee dispute files a petition for judicial review of the Division's decision, the party shall, at the time the petition is filed with the district court, send a copy of the petition for judicial review to the Division's Chief Clerk. The Division and the Department are not considered to be parties to the medical dispute pursuant to Labor Code §§413.031(k-2) and 413.0311(e). The following information must be included in the petition or provided by cover letter:] [(i)the DWC number(s) for the dispute being appealed;] [(ii)the names of the parties;] [(iii)the cause number;] [(iv)the identity of the court; and] [(v)the date the petition was filed with the court.] [(G)The Division shall, upon receipt of the court petition, prepare a record of the Division contested case hearing and submit a copy of the record to the district court. The Division shall assess the party seeking judicial review expenses incurred by the Division in preparing the certified copy of the record, including transcription costs, in accordance with Government Code §2001.177 (relating to Costs of Preparing Agency Record). Upon request, the Division shall consider the financial ability of the party to pay the costs, or any other factor that is relevant to a just and reasonable assessment of costs.] (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.
This agency hereby certifies that the proposal has
been reviewed by legal counsel and found to be within the agency's
legal authority to adopt.
Filed with the Office
of the Secretary of State on March 12, 2012
TRD-201201373 Dirk Johnson
General
Counsel
Texas Department of Insurance, Division of Workers' Compensation
Earliest possible date of adoption: April 22, 2012
For further information, please call: (512) 804-4703
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