(a)Applicability. The applicability of this section is as follows. (1)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, that is: (A)pending on September 1, 2007; (B)remanded to the Division on or after September 1, 2007; or (C)filed on or after September 1, 2007. (2)In resolving non-network disputes regarding 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. [(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 January 15, 2007. Dispute resolution requests filed prior to January 15, 2007 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)(No change.) (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)(No change.) (B)A request may be filed later than one year after the date(s) [dates(s)] of service if: (i) - (iii)(No change.) (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), in a paper billing format, 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), in a paper explanation of benefits format, 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) - (H)(No change.) (3)Employee Dispute Request. An employee who has paid for health care may request medical fee dispute resolution of a refund or reimbursement request that has been denied. The employee's dispute request shall be sent to the MDR Section by mail service, personal delivery or facsimile and shall include: (A) - (B)(No change.) (C)documentation [proof] of employee payment (copies of receipts, provider billing statements, or like documents); (D)(No change.) (4)(No change.) (d)Responses. Responses [Carrier or provider responses] to a request for MDR shall be legible and submitted to the Division and to the requestor in the form and manner prescribed by the Division. (1)(No change.) (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, in a paper explanation of benefits format, 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), in a paper billing format, relevant to the dispute, if different from that originally submitted to the carrier for reimbursement; (iii) - (iv)(No change.) (B) - (E)(No change.) (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, and employee payment receipts, supporting the reasons why the refund request was denied; (B) - (C)(No change.) (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. The party providing the additional information [Division] shall forward a copy of the [any] additional information [received] to all other [the] parties at the time it is submitted to the Division. (2) - (5)(No change.) (f)Appeal 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 MDR decision as provided in §102.5 of this title. (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 in accordance with §148.3 of this title (relating to Requesting a Hearing). (B)The party seeking review of the 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. (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 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 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. (D)At a Division contested case hearing under this paragraph, the parties shall be limited to documentary evidence exchanged and to witnesses reasonably disclosed in said documentary evidence during the medical fee dispute under this subchapter except upon a showing of good cause. 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). (F)A party to a medical fee dispute who has exhausted all administrative remedies may seek judicial review of the Division's decision. Judicial review under this paragraph shall be conducted in the manner provided for judicial review of contested cases under Chapter 2001, Subchapter G of the Government Code. 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. [(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 Division and the Department are not considered to be parties to the medical dispute pursuant to Labor Code §413.031(k). 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 November 30, 2007
TRD-200706005 Norma Garcia
General
Counsel
Texas Department of Insurance, Division of Workers' Compensation
Earliest possible date of adoption: January 13, 2008
For further information, please call: (512) 804-4715
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