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(a)Applicability. This section applies to a request for medical fee dispute resolution for non-network or certain authorized out-of-network health care not subject to a contract, which was filed on or after September 1, 2006. Dispute resolution requests filed prior to September 1, 2006 shall be resolved in accordance with the rules in effect at the time the request was filed. In resolving non-network disputes which are over the amount of payment due for health care determined to be medically necessary and appropriate for treatment of a compensable injury, the role of the Division of Workers' Compensation (Division) is to adjudicate the payment, given the relevant statutory provisions and Division rules. (b)Requestors. The following parties may be requestors in medical fee disputes: (1)the health care provider (provider), including qualified pharmacy processing agents as described in Labor Code §413.0111, in a dispute over the reimbursement of a medical bill(s); (2)the provider in a dispute about the results of a Division audit or review which requires the provider to refund an amount for health care services previously paid by the insurance carrier; (3)the injured employee (employee) in a dispute involving an employee's request for reimbursement from the carrier of medical expenses paid by the employee; or (4)the employee when requesting a refund of the amount the employee paid to the provider in excess of a Division fee guideline. (c)Requests. Requests for medical dispute resolution (MDR) shall be filed in the form and manner prescribed by the Division. Requestors shall file two legible copies of the request with the Division. (1)Timeliness. A requestor shall timely file with the Division's MDR Section or waive the right to MDR. The Division shall deem a request to be filed on the date the MDR Section receives the request. A request for medical fee dispute resolution shall be filed not later than one year after the date(s) of service in dispute, except in the following circumstances: (A)if a dispute under Labor Code Chapter 410 has been filed related to the health care that is the subject of the dispute, the medical dispute must be filed not later than 60 days after the date the requestor received the final decision on compensability or extent of injury, inclusive of all appeals, involving health care for conditions determined to be compensable; (B)if a medical dispute regarding medical necessity has been filed, the medical dispute must be filed not later than 60 days after the date the requestor received the final decision on medical necessity, inclusive of all appeals, related to the health care in dispute and for which the carrier previously denied payment based on medical necessity; or (C)if the dispute relates to a refund notice issued pursuant to a Division audit or review, the dispute must be filed not later than 20 days after the date of the receipt of a refund notice. (2)Provider Request. The provider shall complete the required sections of the request in the form and manner prescribed by the Division. The provider shall file the request with the MDR Section by any mail service or personal delivery. The request shall include: (A)a copy of all medical bill(s) as originally submitted to the carrier and a copy of all medical bill(s) submitted to the carrier for reconsideration in accordance with §133.250 of this chapter (relating to Reconsideration for Payment of Medical Bills); (B)a copy of each explanation of benefits (EOB) relevant to the fee dispute or, if no EOB was received, convincing documentation providing evidence of carrier receipt of the request for an EOB; (C)the form DWC-60 table listing the specific disputed health care and charges in the form and manner prescribed by the Division; (D)when applicable, a copy of the final decision regarding compensability, extent of injury, and/or medical necessity for the health care related to the dispute; (E)a copy of all medical records specific to the dates of service in dispute; (F)a position statement of the disputed issue(s) that shall include: (i)a description of the health care for which payment is in dispute, (ii)the requestor's reasoning for why the disputed fees should be paid or refunded, (iii)how the Labor Code, Division rules, and fee guidelines impact the disputed fee issues, and (iv)how the submitted documentation supports the requestor position for each disputed fee issue; (G)documentation that discusses, demonstrates, and justifies that the payment amount being sought is a fair and reasonable rate of reimbursement in accordance with §134.1 of this title (relating to Medical Reimbursement) when the dispute involves health care for which the Division has not established a maximum allowable reimbursement (MAR), as applicable; and (H)if the requestor is a pharmacy processing agent, a signed and dated copy of an agreement between the processing agent and the pharmacy clearly demonstrating the dates of service covered by the contract and a clear assignment of the pharmacy's right to participate in the MDR process. The pharmacy processing agent may redact any proprietary information contained within the agreement. (3)Employee Refund Dispute Request. An employee who has paid for health care may request medical fee dispute resolution of a refund denied by the provider. The employee's refund request shall be sent to the MDR Section by mail service, personal delivery or facsimile and shall include: (A)the form DWC-60 table listing the specific disputed health care in the form and manner prescribed by the Division; (B)an explanation of the disputed amount that includes a description of the health care, why the disputed amount should be refunded, and how the submitted documentation supports the explanation for each disputed amount; (C)proof of employee payment (copies of receipts); (D)a copy of the carrier's denial of reimbursement relevant to the dispute, or, if no denial was received, convincing evidence of the employee's attempt to obtain reimbursement from the carrier; (4)Division Response to Request. The Division will forward a copy of the request to the respondent. The respondent shall be deemed to have received the request on the acknowledgement date as defined in §102.5 of this title (relating to General Rules for Written Communications to and from the Commission). (d)Responses. Carrier or provider responses to request MDR shall be legible and submitted in the form and manner prescribed by the Division. (1)Timeliness. The response will be deemed timely if received by the Division via mail service, personal delivery, or facsimile within 14 days after the date the respondent received the copy of the requestor's dispute. If the Division does not receive the response information within 14 days of the dispute notification, then the Division may base its decision on the available information. (2)Carrier Response. Upon receipt of the request, the carrier shall complete the required sections of the request form and provide any missing information not provided by the requestor and known to the carrier. (A)The response to the request shall include the completed request form and: (i)all initial and reconsideration EOBs related to the health care in dispute not submitted by the requestor or a statement certifying that the carrier did not receive the provider's disputed billing prior to the dispute request; (ii)a copy of all medical bill(s) relevant to the dispute, if different from that originally submitted to the carrier for reimbursement; (iii)a copy of any pertinent medical records or other documents relevant to the fee dispute; (iv)a statement of the disputed fee issue(s), which includes: (I)a description of the health care in dispute; (II)a position statement of reasons why the disputed medical fees should not be paid; (III)a discussion of how the Labor Code and Division rules, including fee guidelines, impact the disputed fee issues; and (IV)a discussion regarding how the submitted documentation supports the respondent's position for each disputed fee issue; and (V)documentation that discusses, demonstrates, and justifies that the amount the respondent paid is a fair and reasonable reimbursement in accordance with Labor Code §413.011 and §134.1 of this title if the dispute involves health care for which the Division has not established a MAR, as applicable. (B)The response shall address only those denial reasons presented to the requestor prior to the date the request for MDR was filed with the Division and the other party. Responses shall not address new or additional denial reasons or defenses after the filing of a request. Any new denial reasons or defenses raised shall not be considered in the review. (C)If the carrier did not receive the provider's disputed billing or the employee's reimbursement request relevant to the dispute prior to the request, the carrier shall so certify when the carrier files the request form with the Division. (D)If the dispute has not been resolved and involves compensability or extent of injury the carrier shall attach a copy of any related Plain Language Notice 11 (PLN 11) in accordance with §124.2 of this title (relating to Carrier Reporting and Notification Requirements). (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 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)MDR Action. The Division will review the completed request and response to determine appropriate MDR action. (1)Request for Additional Information. The 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 no later than 14 days after receipt of this request. If the Division does not receive the requested additional information within 14 days after receipt of the request, then the Division may base its decision on the information available. (2)Abatement of Dispute. If the carrier has raised a dispute pertaining to compensability, or extent of injury for the claim, in accordance with §124.2 of this title, the request for medical fee dispute resolution will be held in abatement until those disputes have been resolved by a final decision of the Division, inclusive of all appeals, or receipt of written notice from the carrier. (3)Issues Raised by the Division. The Division may raise issues in the 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 rules. (4)Dismissal. The Division may dismiss a request for 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; (C)the Division determines that the medical bills in the dispute have not been submitted to the carrier for reconsideration; (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 to an employee by a network provider subject to Insurance Code Chapter 1305; or (G)if the request contains unresolved medical necessity issues, the Division shall notify the parties of the review requirements pursuant to §133.308 of this subchapter (relating to Medical Dispute Resolution by Independent Review Organizations) and will dismiss the request in accordance with the process outlined in §133.305 of this subchapter (relating to Medical Dispute Resolution--General). (H)the request for medical fee dispute resolution involves contract rates not pertaining to networks certified under Insurance Code Chapter 1305 and not in accordance with Labor Code §413.011 or §504.053; (I)the request for medical fee dispute resolution was not submitted in compliance with the provisions of the Labor Code and this chapter; or (J)the Division determines that good cause exists to dismiss the request. (5)Decision. The Division shall send a decision to the disputing parties and post the decision on the Department Internet website. (6)Division Fee. The Division may assess a fee in accordance with §133.305 of this subchapter. (f)Appeal. A party to a medical fee dispute may seek judicial review of the decision by filing a petition in a Travis County district court not later than the 30th day after the date on which the decision is received by the appealing party. The parties will be deemed to have received the decision on the acknowledgement date as defined in §102.5 of this title. Any decision that is not timely appealed becomes final. If a party to a medical fee dispute files a petition for judicial review of the MDR Section 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. The following information must be included in the petition or provided by cover letter: (1)the MDR Section tracking number for the dispute being appealed; (2)the names of the parties; (3)the cause number; (4)the identity of the court; and (5)the date the petition was filed with the court. (g)Record for Appeal. The Division shall upon receipt of the court petition prepare a record of the MDR Section review 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 and copying the record. The record shall contain: (1)the MDR Section decision; (2)the request for MDR; (3)all documentation and written information submitted by the requestor; (4)all documentation and written information submitted by the respondent; (5)other documents contained in the MDR Section files (e.g. correspondence, orders for production; (6)copies of any pertinent medical literature or other documentation utilized to support the decision or, where such documentation is subject to copyright protection or is voluminous, then a listing of such documentation referencing the portion(s) of each document utilized; (7)if not specified in the decision, citations to the particular provisions in statutes, rules, and other authorities that are utilized to support the decision; and (8)signed and certified custodian of records affidavit; (h)Letter of Clerical Correction. Upon receipt of a Division decision, either party may request a clerical correction of an 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 clerical correction does not alter the deadlines for appeal.
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 June 12, 2006
TRD-200603183 Norma Garcia
General Counsel
Texas Department of Insurance, Division of Workers' Compensation
Earliest possible date of adoption: July 23, 2006
For further information, please call: (512) 804-4288
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