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(a)Applicability. This rule applies as follows: (1)This rule applies to a request for medical fee dispute resolution for which the initial dispute resolution request was filed on or after January 1, 2002. Dispute resolution requests filed prior to January 1, 2002 shall be resolved in accordance with the rules in effect at the time the request was filed. In resolving disputes 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 commission is to adjudicate the payment, given the relevant statutory provisions and commission rules. Medical necessity is not an issue in a medical fee dispute. (2)If there is a medical fee dispute with respect to the health care for which there is a medical necessity dispute, the requestor shall file a request for medical fee dispute resolution pursuant to this section and a request for medical necessity dispute resolution pursuant to §133.308 of this title (relating to Medical Dispute Resolution By Independent Review Organization). (b)Parties. The following persons may be requestors and respondents in medical fee disputes: (1)the health care provider (provider) and the insurance carrier (carrier) in a dispute of a medical bill; (2)the injured employee (employee) and the carrier in a dispute involving an employee's request for reimbursement of medical expenses; (3)the carrier and the provider in a dispute involving a carrier's refund request; (4)the provider and the commission in a dispute involving a commission refund order issued pursuant to an audit or review. (c)Requests. A request for medical dispute resolution of a medical fee dispute must be complete and must be timely filed with the commission Medical Review Division (division). (d)Timeliness. Requests for medical fee dispute resolution shall be filed timely with the division. A person or entity who fails to timely file a request for medical fee dispute resolution waives the right to medical dispute resolution. The commission shall deem a request to be filed on the date the division receives a complete request and timeliness shall be determined as follows: (1)A request for medical fee dispute resolution on a carrier denial or reduction, for reasons other than lack of medical necessity, of a medical bill or an employee reimbursement request shall be considered timely if it is filed with the division: (A)no earlier than the 28th day after the date the requestor had filed the request for reconsideration with the carrier; and (B)no later than 60 days after the date the carrier took final action on the request for reconsideration. (2)A request for medical fee dispute resolution on a provider denial or reduction of a carrier request for refund of payment for health care shall be considered timely if it is filed with the division no later than 60 days after the date the provider took final action on the refund request. (3)A request for medical fee dispute resolution on a commission refund order issued pursuant to a commission audit or review shall be considered timely if a request for a hearing is filed with the commission Chief Clerk of Proceedings, Hearing Division, not later than 20 days after the date of receipt of the refund order. (e)Complete Request (General). All provider and carrier requests for medical fee dispute resolution shall be made in the form, format, and manner prescribed by the commission. (Requests of medical dispute resolution on medical fee disputes involving an employee's request for reimbursement of medical expenses are governed by subsection (f) of this section). (1)Each request shall be legible, shall include only a single copy of each document, and shall include: (A)documentation of the request for and response to reconsideration (when a provider is requesting dispute resolution on a carrier reduction or denial of a medical bill) or, if the carrier failed to respond to the request for reconsideration, convincing evidence of the carrier's receipt of that request; (B)an identical copy of all medical bill(s) relevant to the fee dispute, as submitted for reconsideration in accordance with §133.304 of this title (relating to Medical Bill Payments and Denials); (C)a copy of each explanation of benefits (EOB) or response to the refund request relevant to the fee dispute or, if no EOB was received, convincing evidence of a provider request for an EOB from the carrier, (D)a copy of medical records, clinical notes, diagnostic test results, treatment plans, and other documents relevant to the fee dispute; (E)a 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 Texas Labor Code and commission rules, including treatment guidelines and fee guidelines, impact the disputed fee issues, and (iv)how the submitted documentation supports the requestor position for each disputed fee issue; (F)if the dispute involves health care for which the commission has not established a maximum allowable reimbursement, documentation that discusses, demonstrates, and justifies that the payment amount being sought is a fair and reasonable rate of reimbursement in accordance with §133.1 of this title (relating to Definitions); (G)a table listing the disputed health care in the form, format, and manner prescribed by the commission; and (H)if the carrier has raised a dispute pertaining to liability for the claim, compensability, or extent of injury, in accordance with §124.2 of this title (relating to Carrier Reporting and Notification Requirements), the requestor shall file with the request, proof that a Benefit Review Conference (BRC) has been requested under Chapter 141 of this title (relating to Benefit Review Conference) by either the employee or the licensed health care provider as a subclaimant. The commission shall adjudicate the medical dispute issues and enter a decision on those issues conditional upon final adjudication of the issues of liability for the claim, compensability, or extent of injury. (2)Prior to submission, any documentation that contains confidential information regarding a person other than the injured employee for that claim or a party in the dispute, must be redacted by the party submitting the documentation, to protect the confidential information and the privacy of the individual. (3)If the request for medical fee dispute resolution does not contain all the components required by the commission-prescribed form and by this subsection, the requestor may amend and resubmit the request to include all the required components as long as the amended request is filed within the time frames required by subsection (d) of this section. (f)Employee Reimbursement Dispute. An employee who has paid for health care may request medical dispute resolution of a denied reimbursement. The employee may only pursue reimbursement up to the amount the employee paid the provider. Reimbursement shall be fair and reasonable in accordance with commission rules, and shall not exceed the Maximum Allowable Reimbursement (MAR) as established in the appropriate fee guideline, or in the absence of a fee guideline, the amount determined to be fair and reasonable for the health care. Health care requiring preauthorization or concurrent review pursuant to §134.600 of this title (relating to Treatments and Services Requiring Preauthorization) must have received the preauthorization or concurrent review approval. The employee request shall be made in the form, format, and manner prescribed by the commission. The request must be legible, must contain only a single copy of each document, and must include: (1)an explanation of the disputed fee issue(s); (2)proof of employee payment for the health care for which the employee is requesting reimbursement; (3)a copy of any explanations of benefits relevant to the dispute, or, if no EOB was received, convincing evidence of carrier receipt of employee request for reimbursement; and (4)a copy of medical records, clinical notes, diagnostic test results, treatment plans, and other documents relevant to the dispute, that are in the employee's possession. (g)Filing. The requestor shall file two copies of the complete request with the division. (1)If the respondent is a carrier, the division shall forward a copy of the request to the carrier. The commission shall deem the carrier to have received the request on the acknowledgment date as defined in §133.1 of this title. If the division forwards the request to the carrier via its Austin representative, the representative shall sign for the request. (2)If the respondent is a provider, the commission shall forward a copy of the request to the provider by regular U.S. mail service. The commission shall deem the provider to have received the request on the acknowledgment date as defined in §133.1 of this title. (h)Response. The respondent shall file the response to a request for medical dispute resolution of a medical fee dispute, with the division. (i)Timeliness of Response. A respondent who fails to timely file a request for medical dispute resolution waives the right to respond. The commission shall deem a response to be filed on the date the division receives a response. If the respondent does not respond timely, the commission shall issue a decision based on the request. The response will be considered timely if received by the commission within 14 days after the date the respondent received the copy of the request. (j)Complete Response. All responses to requests for medical fee dispute resolution shall be made on the form and in the manner prescribed by the commission. (1)Each response shall be legible, include only a single copy of each document, and, unless previously provided in the request, shall include: (A)documentation of carrier response to reconsideration in accordance with commission rules; (B)a copy of all medical bill(s) relevant to the dispute, as originally submitted to the carrier for reimbursement; (C)a copy of all medical audit summaries and/or explanations of benefits relevant to the fee dispute, or a statement certifying that the carrier did not receive the provider disputed billing relevant to the dispute; (D)a copy of medical records, clinical notes, diagnostic test results, treatment plans, and other documents relevant to the dispute; (E)a statement of the disputed fee issue(s), which includes: (i)a description of the health care in dispute; (ii)a statement of the reasons that the disputed medical fees should not be paid, (iii)a discussion of how the Texas Labor Code and commission rules, including fee guidelines, impact the disputed fee issues, and (iv)a discussion regarding how the submitted documentation supports the respondent position for each disputed fee issue; and (F)if the dispute involves health care for which the commission has not established a maximum allowable reimbursement, documentation that discusses, demonstrates, and justifies that the amount the respondent paid is a fair and reasonable rate of reimbursement in accordance with §133.1 of this title. (2)The response shall address only those issues raised by the requestor and may not include any reason that was not previously given for the adverse decision by the utilization review agent. (k)Filing of Response. The respondent shall file a copy of the response with the division and with the other party to the dispute. (l)Additional Information. The commission may request additional information from either party to review the medical fee issues in dispute. The additional information shall be received by the division within 14 days of receipt of the request for additional information. (m)Dismissal. The commission may dismiss a complete request for medical fee dispute resolution if: (1)the requestor informs the commission, or the commission otherwise determines, that the dispute no longer exists; (2)the individual or entity requesting medical fee dispute resolution is not a proper party to the dispute per subsection (b) of this section; (3)the commission determines that the medical bills in the dispute have not been properly submitted to the carrier; (4)the fee disputes for the date(s) of health care in dispute have been previously adjudicated by the commission; or (5)the commission determines that good cause exists to dismiss the request. (n)Decision. The commission shall send the commission decision to the parties to the dispute and post the decision on the commission Internet website after confidential information has been redacted. (o)Fee. The commission may assess a fee in accordance with Texas Labor Code §413.020 of this title. (relating to Commission Charges). (p)Appeal. A party to a medical fee dispute may appeal the commission decision by filing a written request for a State Office of Administrative Hearings (SOAH) hearing with the Chief Clerk of Proceedings, Division of Hearings in accordance with §148.3 of this title (relating to Requesting a Hearing). (1)the appeal must be filed no later than 20 days from the date the party received the commission decision. The date of receipt of the decision shall be the acknowledgment date as defined in §133.1 of this title. The carrier representative shall sign for the decision. (2)A party who has exhausted the party's administrative remedies under this subtitle and who is aggrieved by a final decision of the SOAH may seek judicial review of the decision. Judicial review under this subsection shall be conducted in the manner provided for judicial review of contested cases under Subchapter G, Chapter 2001, Government Code. (3)The commission shall post the SOAH decision on the commission Internet website after confidential information has been redacted. (q)Notice of Appeal. The party appealing the commission decision shall deliver a copy of its written request for a SOAH hearing to all other parties involved in the dispute.
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 October 19, 2001
TRD-200106295 Susan Cory
General Counsel
Texas Workers' Compensation
Commission
Earliest possible date of adoption: December 2, 2001
For further information, please call: (512) 804-4287
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