(a)Applicability. The applicability of this section is as follows. (1)This section applies to a request to the division for medical fee dispute resolution (MFDR) as authorized by the Texas Workers' Compensation Act [for non-network or certain authorized out-of-network health care not subject to a contract,] that is [remanded to the Division or] filed on or after June 1, 2012 [May 25, 2008]. Dispute [Except as provided in paragraph (2) of this subsection, dispute] resolution requests filed prior to June 1, 2012 [ May 25, 2008], shall be resolved in accordance with the statutes and rules in effect at the time the request was filed. [(2)Subsection (f) of 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 for adjudication by the Division 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) [(3)] 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 [Division of Workers' Compensation (Division)] is to adjudicate the payment, given the relevant statutory provisions and division [Division ] rules. (3)In accordance with Labor Code §504.055 a request for medical fee dispute resolution that involves a first responder's request for reimbursement of medical expenses paid by the first responder will be accelerated by the division and given priority. The first responder shall provide notice to the division that the request involves a first responder. (b)Requestors. The following parties may be requestors in medical fee disputes: (1)the health care provider [(provider)], or a qualified pharmacy processing agent, as described in Labor Code §413.0111, in a dispute over the reimbursement of a medical bill(s); (2)the health care provider in a dispute about the results of a division [Division] or insurance carrier audit or review which requires the health care 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 injured employee's request for reimbursement from the insurance carrier of medical expenses paid by the injured employee; [or] (4)the injured employee when requesting a refund of the amount the injured employee paid to the health care provider in excess of a division [Division] fee guideline; or[.] (5)a subclaimant in accordance with §140.6 of this title (relating to Subclaimant Status: Establishment, Rights, and Procedures), §140.7 of this title (relating to Health Care Insurer Reimbursement under Labor Code §409.0091), or §140.8 of this title (relating to Procedures for Health Care Insurers to Pursue Reimbursement of Medical Benefits under Labor Code §409.0091), as applicable. (c)Requests. Requests for MFDR [medical dispute resolution (MDR)] shall be filed in the form and manner prescribed by the division [Division]. Requestors shall file two legible copies of the request with the division [ Division]. (1)Timeliness. A requestor shall timely file the request with the division's MFDR [Division's MDR] Section or waive the right to MFDR [MDR]. The division [Division] shall deem a request to be filed on the date the MFDR [MDR] Section receives the request. A decision by the MFDR Section that a request was not timely filed is not a dismissal and may be appealed pursuant to subsection (g) of this section. (A)A request for MFDR [medical fee dispute resolution] that does not involve issues identified in subparagraph (B) of this paragraph shall be filed no later than one year after the date(s) of service in dispute. (B)A request may be filed later than one year after the date(s) of service if: (i)a related compensability, extent of injury, or liability dispute under Labor Code Chapter 410 has been filed, the medical fee dispute shall be filed not later than 60 days after the date the requestor receives the final decision, inclusive of all appeals, on compensability, extent of injury, or liability; (ii)a medical dispute regarding medical necessity has been filed, the medical fee 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 insurance carrier previously denied payment based on medical necessity; or (iii)the dispute relates to a refund notice issued pursuant to a division [Division] audit or review, the medical fee dispute must be filed not later than 60 days after the date of the receipt of a refund notice. (2)Health Care Provider, Subclaimant, or Pharmacy Processing Agent Request. The requestor [ provider] shall provide [complete] the following information and records with the [required sections of the] request for MFDR in the form and manner prescribed by the division [Division]. The provider shall file the request with the MFDR [MDR] Section by any mail service or personal delivery. The request shall include: (A)the name, address, and contact information of the requestor; (B)the name of the injured employee; (C)the date of the injury; (D)the date(s) of the service(s) in dispute; (E)the place of service; (F)the treatment or service code(s) in dispute; (G)the amount billed by the health care provider for the treatment(s) or service(s) in dispute; (H)the amount paid by the workers' compensation insurance carrier for the treatment(s) or service(s) in dispute; (I)the disputed amount for each treatment or service in dispute; (J) [(A)] a paper copy of all medical bill(s) related to the dispute, [in a paper billing format using an appropriate DWC approved paper billing format,] as originally submitted to the insurance carrier in accordance with Chapter 133 of this title (relating to General Medical Provisions) and a paper copy of all medical bill(s) submitted to the insurance carrier for reconsideration in accordance with §133.250 of this chapter (relating to Reconsideration for Payment of Medical Bills); (K) [(B)] a paper copy of each explanation of benefits (EOB) related to the dispute as originally submitted to the health care provider in accordance with Chapter 133 of this title[, in a paper explanation of benefits format, relevant to the fee dispute] or, if no EOB was received, convincing documentation providing evidence of insurance 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;] (L) [(D)] when applicable, a copy of the final decision regarding compensability, extent of injury, liability and/or medical necessity for the health care related to the dispute; (M) [(E)] a copy of all applicable medical records related [specific] to the dates of service in dispute; (N) [(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,] (i) [(ii)] the requestor's reasoning for why the disputed fees should be paid or refunded, (ii) [(iii)] how the Labor Code and division[, Division] rules, including [ and] fee guidelines, impact the disputed fee issues, and (iii) [(iv)] how the submitted documentation supports the requestor's [requestor] position for each disputed fee issue; (O) [(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) or §134.503 of this title (relating to Pharmacy Fee Guideline) when the dispute involves health care for which the division [Division ] has not established a maximum allowable reimbursement (MAR) or reimbursement rate, as applicable; [and] (P) [(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 MFDR [MDR] process. The pharmacy processing agent may redact any proprietary information contained within the agreement; and[.] (Q)any other documentation that the requestor deems applicable to the medical fee dispute. (3)Injured Employee Dispute Request. An injured employee who has paid for health care may request MFDR [ medical fee dispute resolution] of a refund or reimbursement request that has been denied. The injured employee's dispute request shall be sent to the MFDR [MDR] Section in the form and manner prescribed by the division by mail service, personal delivery or facsimile and shall include: (A)the name, address, and contact information of the injured employee; (B)the date of the injury; (C)the date(s) of the service(s) in dispute; (D)a description of the services paid; (E)the amount paid by the injured employee; (F)the amount of the medical fee in dispute; [(A)the form DWC-60 table listing the specific disputed health care in the form and manner prescribed by the Division]; (G)[(B)] an explanation of [the disputed amount that includes a description of the health care,] why the disputed amount should be refunded or reimbursed, and how the submitted documentation supports the explanation for each disputed amount; (H)[(C)] Proof of employee payment (including copies of receipts, health care provider billing statements, or similar documents); and (I)[(D)] a copy of the insurance carrier's or health care provider's denial of reimbursement or refund relevant to the dispute, or, if no denial was received, convincing evidence of the injured employee's attempt to obtain reimbursement or refund from the insurance carrier or health care provider.[;] (4)Division Response to Request. The division [ Division] will forward a copy of the request and the documentation submitted in accordance with paragraph (2) or (3) of this subsection to the respondent. The respondent shall be deemed to have received the request on the acknowledgment date as defined in §102.5 of this title (relating to General Rules for Written Communications to and from the Commission). (d)Responses. Responses to a request for MFDR [ MDR] shall be legible and submitted to the division [ Division] and to the requestor in the form and manner prescribed by the division [Division]. (1)Timeliness. The response will be deemed timely if received by the division [Division] via mail service, personal delivery, or facsimile within 14 calendar days after the date the respondent received the copy of the requestor's dispute. If the division [Division] does not receive the response information within 14 calendar days of the dispute notification, then the division [Division] may base its decision on the available information. (2)[Carrier] Response. Upon receipt of the request, the respondent [carrier] shall provide [complete required sections of the request form and provide] any missing information not provided by the requestor and known to the respondent [carrier]. The respondent shall also provide the following information and records: (A)the name, address, and contact information of the respondent; [The response to the request shall include the completed request form and:] (B)[(i)] a paper copy of all initial and reconsideration EOBs related to the dispute, [in a paper explanation of benefits format] as originally submitted to the health care provider in accordance with Chapter 133 of this title [using an appropriate DWC approved paper billing format], related to the health care in dispute not submitted by the requestor or a statement certifying that the respondent [ carrier] did not receive the health care provider's disputed billing prior to the dispute request; (C)[(ii)] a paper copy of all medical bill(s) related to the dispute, submitted in accordance with Chapter 133 of this title [in a paper billing format using an appropriate DWC approved paper billing format, relevant to the dispute,] if different from that originally submitted to the insurance carrier for reimbursement; (D)[(iii)] a copy of any pertinent medical records or other documents relevant to the fee dispute not already provided by the requestor; (E)[(iv)] a statement of the disputed fee issue(s), which includes: (i)[(I)] a description of the health care in dispute; (ii)[(II)] a position statement of reasons why the disputed medical fees should not be paid; (iii)[(III)] a discussion of how the Labor Code and division [Division] rules, including fee guidelines, impact the disputed fee issues; [and] (iv)[(IV)] a discussion regarding how the submitted documentation supports the respondent's position for each disputed fee issue; and (v)[(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 or §134.503 of this title if the dispute involves health care for which the division [Division] has not established a MAR or reimbursement rate, as applicable. (F)[(B)] The response shall address only those denial reasons presented to the requestor prior to the date the request for MFDR [MDR] was filed with the division [Division] and the other party. Any new denial reasons or defenses raised shall not be considered in the review. If the response includes unresolved issues of compensability, extent of injury, liability, or medical necessity, the request for MFDR [MDR] will be dismissed in accordance with subsection (f)(3)(B) or (C) [(e)(3)(G) or (H)] of this section. (G)[(C)] If the respondent [ carrier] did not receive the health care provider's disputed billing or the employee's reimbursement request relevant to the dispute prior to the request, the respondent [carrier ] shall include that information in a written statement [in the response the carrier submits to the Division]. (H)[(D)] If the medical fee dispute involves compensability, extent of injury, or liability, the insurance carrier shall attach a copy of any related Plain Language Notice in accordance with §124.2 of this title (relating to Carrier Reporting and Notification Requirements). Cont'd...
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