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(a)Applicability. This rule applies to a request for medical fee dispute resolution for which the dispute resolution request was filed on or after January 1, 2003. Dispute resolution requests filed prior to January 1, 2003 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. (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 timely filed with the commission's Medical Review Division (division). (d)Timeliness. A person or entity who fails to timely file a request waives the right to medical dispute resolution. The commission shall deem a request to be filed on the date the division receives the request, and timeliness shall be determined as follows: (1)A request for medical dispute resolution on a carrier denial or reduction of a medical bill pursuant to §133.304 of this title (relating to Medical Payments and Denials) or an employee reimbursement request shall be considered timely if it is filed with the division no later than one (1) year after the date(s) of service in dispute. (2)A request for medical 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 pursuant to the provisions in §133.304 and no later than one (1) year from the date(s) of service in dispute. (3)A request for medical 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)Request (General). All provider and carrier requests for medical dispute resolution shall be made in the form, format, and manner prescribed by the commission. (Requests for 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)The requestor shall file two copies of the request with the division by any mail service or personal delivery. (A)when the respondent is an insurance carrier, the division shall forward a copy of the request to the insurance carrier. The division shall deem the insurance carrier to have received the request on the acknowledgement date as defined in §133.1 of this title (relating to Definitions for Chapter 133, Benefits-Medical Benefits). If the division forwards the request to the insurance carrier via its Austin representative, the representative shall sign for the request. (B)when the respondent is a health care provider, the division shall forward a copy of the request to the health care provider by a verifiable means of delivery. The division shall deem the health care provider to have received the request on the acknowledgement date as defined in §133.1 of this title. (2)Each copy of the request shall be legible, include only a single copy of each document, and shall include: (A)a copy of all medical bill(s) as originally submitted to the carrier for reconsideration in accordance with §133.304; (B)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 carrier receipt of the provider request for an EOB; (C)a table listing the specific disputed health care and charges in the form, format, and manner prescribed by the commission; and (D)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 request for an IRO will be held in abeyance until those disputes have been resolved by a final decision of the commission. (3)Upon receipt of the request, the respondent shall: (A)complete the remaining sections of the request form other than information for an IRO review pursuant to the requirements under §133.308; (B)provide any missing information required on the form, including absent EOBs not submitted by the requestor with the request; and (C)file the completed request with the division and the requestor within fourteen (14) calendar days of respondent's receipt of the request. (4)If the dispute has already been resolved, the respondent shall certify this on the form. If the respondent did not receive the provider's disputed billing or the employee's reimbursement request relevant to the dispute prior to the request, the respondent shall include certification of this when the respondent files the request form with the division. If dispute has not been resolved and involves compensability/extent of injury, the respondent shall attach any related TWCC-21s in accordance with §124.2 of this title. (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 Preauthorization, Concurrent Review, and Voluntary Certification of Health Care) must have received the preauthorization or concurrent review approval. The employee's request shall be filed with the division in the form, format, and manner prescribed by the commission. The requestor shall submit two copies of the request to the division by any mail service or personal delivery and the division will forward one copy of the request to the insurance carrier via its Austin representative, the representative shall sign for the request. 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 (include receipts of payment made); and (3)A copy of any EOB relevant to the dispute, or, if no EOB was received, convincing evidence of carrier receipt of employee request for reimbursement. (g)Commission Notice. The respondent shall file the completed request with the requestor and with the division by transmission of facsimile. (1)The commission shall review the completed request to determine appropriate medical dispute resolution action. (2)If the request contains unresolved medical necessity issues, the commission shall notify the parties of the review requirements pursuant to §133.308. (3)If the request contains only medical fee disputes, the commission shall notify the parties and require the requestor to send to the commission, two copies of additional documentation relevant to the fee dispute. The additional documentation 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)a copy of any pertinent medical records or other documents relevant to the fee dispute; (C)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, and fee guidelines, impact the disputed fee issues, and (iv)how the submitted documentation supports the requestor position for each disputed fee issue; (D)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) and §134.1 of this title (relating to Use of the Fee Guidelines); (E)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. Un-redacted information or evidence shall not be considered in resolving the medical fee dispute. (F)The additional documentation shall be received by the division within 14 days of the requestor's receipt of notice pursuant to this rule. (4)If the respondent is a carrier, the commission shall forward a copy of the additional documentation to the carrier. The commission shall deem the carrier to have received the documentation on the acknowledgment date as defined in §133.1 of this title. If the division forwards the documentation to the carrier via its Austin representative, the representative shall sign for the request. (5)If the respondent is a provider, the commission shall forward a copy of the request to the provider by a verifiable means of delivery. 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 the requestor's additional documentation for the medical fee dispute, with the division and the requestor. (i)Timeliness of Response. A respondent who fails to timely file a response 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 requestor's additional documentation. (j)Complete Response. All responses to requestor's additional documentation 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 and requestor's additional documentation, 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, if different from that as originally submitted to the carrier for reimbursement; (C)a copy of all medical audit summaries and/or explanations of benefits (EOBs) relevant to the fee dispute, or a statement certifying that the carrier did not receive the provider's disputed billing prior to the request; (D)a copy of any pertinent medical records or other documents relevant to the fee 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 or refunded; (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; (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 Texas Labor Code §413.011 and §§133.1 and 134.1 of this title; and (G)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. Unredacted information or evidence shall not be considered in resolving the medical fee dispute. (2)The response shall address only those denial reasons presented to the requestor prior to the date the request for medical dispute resolution 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. (k)Filing of Response. The respondent shall file a copy of the response with the division and the requestor within 14 days of receipt of the requestor's additional documentation. (l)Additional Information. The commission may request other additional information from either party to review the medical fee issues in dispute. The other additional information shall be received by the division within 14 days of receipt of this request. (m)Dismissal. A dismissal does not constitute a decision. The commission may dismiss a 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 for reconsideration pursuant to §133.304; (4)the fee disputes for the date(s) of health care in dispute have been previously adjudicated by the commission; (5)the request for dispute resolution is untimely; or (6)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 separate fee in accordance with Texas Labor Code §413.020 (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)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. (3)Notwithstanding other provisions of this rule or any other rules, the acquiring, providing, assembling, filing and offering of documents at any de novo hearing (a new hearing based upon evidence admitted at the SOAH hearing) conducted by the State Office of Administrative Hearings on or after March 1, 2003, whether or not previously exchanged, is the responsibility of the requestor and respondent. Admission and use of such documents at the hearing are controlled by the procedural Rules of the State Office of Administrative Hearings. The commission will not file a copy of the record of the medical fee review by the division with SOAH or any party for a hearing scheduled to be conducted by SOAH (or continued to a date) on or after March 1, 2003. (4)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 that 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. (5)the commission shall post the SOAH decision on the commission Internet website after confidential information has been redacted.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of
the Secretary of State on December 12, 2002
TRD-200208231 Susan Cory
General Counsel
Texas Workers' Compensation Commission
Effective date: January 1,
2003
Proposal publication date: September 13, 2002
For further information, please call: (512) 804-4287
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