(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 [that is filed on or after
June 1, 2012].
(1)Dispute resolution requests must [
filed prior to June 1, 2012, shall] be resolved in accordance
with the statutes and rules in effect at the time the request was
filed.
(2) - (3)(No change.)
(4)The 2020 amendments regarding
electronic submission of dispute requests are effective February 1,
2021.
(b)(No change.)
(c)Requests. Requests for MFDR must [shall
] be legible and 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 must [shall]
timely file the request with the division [division's
MFDR Section] or waive the right to MFDR. The division will [
shall] deem a request to be filed on the date the division [
MFDR Section] receives the request. A decision by the division
[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) - (B)(No change).
(2)Health Care Provider or Pharmacy Processing Agent
Request. [The requestor shall provide the following information
and records with the request for MFDR in the form and manner prescribed
by the division.] The requestor must send [provider
shall file] the request to [with] the division
in the form and manner prescribed by the division [MFDR
Section] by any mail service, [or] personal
delivery, or electronic transmission as described in §102.5
of this title (relating to General Rules for Written Communications
to and from the Commission). The request must [shall
] include:
(A) - (I)(No change.)
(J)a [paper] copy of all medical bills [
bill(s)] related to the dispute, as described in §133.10
of this chapter (concerning Required Billing Forms/Formats) or §133.500
(concerning Electronic Formats for Electronic Medical Bill Processing) as
originally submitted to the insurance carrier in accordance with this
chapter, and a [paper] copy of all medical bills
[bill(s)] submitted to the insurance carrier for
an appeal in accordance with §133.250 of this chapter (concerning
Reconsideration for Payment of [relating to General]
Medical Bills [Provisions]);
(K)[a paper copy of] each explanation of
benefits or e-remittance (collectively "EOB")
related to the dispute as originally submitted to the health care
provider in accordance with this chapter or, if no EOB was received,
convincing documentation providing evidence of insurance carrier receipt
of the request for an EOB;
(L) - (Q)(No change.)
(3)Subclaimant Dispute Request. [The requestor
shall provide the appropriate information with the request that is
consistent with the provisions of §140.6 or §140.8 of this
title.]
(A)A request made by a subclaimant under
Labor Code §409.009 (relating to Subclaims) must [shall
] comply with §140.6 of this title (concerning Subclaimant
Status: Establishment, Rights, and Procedures) and submit the
required documents to the division [Division
required thereunder].
(B)A request made by a subclaimant under
Labor Code §409.0091 (relating to Reimbursement Procedures
for Certain Entities) must [shall] comply with the
document requirements of §140.8 of this title (concerning
Procedures for Health Care Insurers to Pursue Reimbursement of Medical
Benefits under Labor Code §409.0091) and submit the required
documents to the division [Division required
thereunder].
(4)Injured Employee Dispute Request. An injured employee
who has paid for health care may request MFDR of a refund or reimbursement
request that has been denied. The injured employee must send
the request [employee's dispute request shall be sent]
to the division [MFDR Section] in the form and
manner prescribed by the division by mail service, personal delivery
, or electronic transmission as described in §102.5
of this title [facsimile] and must [shall
] include:
(A) - (I)(No change.)
(5)Division Response to Request. The division will
forward a copy of the request and the documentation submitted in accordance
with paragraph (2), (3), or (4) 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 must [
shall] be legible and submitted to the division and to the requestor
in the form and manner prescribed by the division.
(1)Timeliness. The response will be deemed timely
if received by the division through [via] mail
service, personal delivery, or electronic transmission as described
in §102.5 of this title, [facsimile] within
14 calendar 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 calendar days of the dispute notification, then
the division may base its decision on the available information.
(2)Response. On [Upon] receipt
of the request, the respondent must [shall]
provide any missing information not provided by the requestor and
known to the respondent. The respondent must [shall]
also provide the following information and records:
(A)the name, address, and contact information of the
respondent;
(B)[a paper copy of] all initial and appeal
EOBs related to the dispute, as originally submitted to the health
care provider in accordance with this chapter, related to the health
care in dispute not submitted by the requestor or a statement certifying
that the respondent did not receive the health care provider's disputed
billing before [prior to] the dispute request;
(C)[a paper copy of] all medical bill(s)
related to the dispute, submitted in accordance with this chapter
if different from that originally submitted to the insurance carrier
for reimbursement;
(D)[a copy of] any pertinent medical records
or other documents relevant to the fee dispute not already provided
by the requestor;
(E) - (G)(No change.)
(H)If the medical fee dispute involves compensability,
extent of injury, or liability, the insurance carrier must [
shall] attach [a copy of] any related Plain Language
Notice in accordance with §124.2 of this title (concerning
Insurance [relating to] Carrier Reporting and Notification
Requirements).
(I)If the medical fee dispute involves medical necessity
issues, the insurance carrier must [shall] attach
[a copy of] documentation that supports an adverse determination
in accordance with §19.2005 of this title (concerning [
relating to] General Standards of Utilization Review).
(e) - (h)(No change.)
The agency certifies that legal counsel has reviewed
the proposal and found it to be within the state agency's legal authority
to adopt.
Filed with the Office
of the Secretary of State on September 22, 2020
TRD-202003900 Kara Mace
Deputy Commissioner of Legal Services
Texas Department of Insurance, Division of Workers' Compensation
Earliest possible date of adoption: November 8, 2020
For further information, please call: (512) 804-4703
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