Current through Reg. 49, No. 38; September 20, 2024
(a) The health care
provider must submit all medical bills to the insurance carrier except when
billing the employer in accordance with subsection (j) of this
section.
(b) Except as provided in
Labor Code §
408.0272(b),
(c), or (d), a health care provider must not
submit a medical bill later than the 95th day after the date the services are
provided.
(1) If a designated doctor refers an
injured employee for additional testing or evaluation under §
127.10 of this title, the 95-day
period for timely submission of the bill begins on the date of service of the
additional testing or evaluation.
(2) In accordance with subsection (c) of the
statute, the health care provider must submit the medical bill to the correct
workers' compensation insurance carrier no later than the 95th day after the
date the health care provider is notified of the health care provider's
erroneous submission of the medical bill.
(3) A health care provider who submits a
medical bill to the correct workers' compensation insurance carrier must
include a copy of the original medical bill submitted, a copy of the
explanation of benefits (EOB) if available, and sufficient documentation to
support why one or more of the exceptions for untimely submission of a medical
bill under §408.0272 should be applied. The medical bill submitted by the
health care provider to the correct workers' compensation insurance carrier is
subject to the billing, review, and dispute processes established by Chapter
133, including §133.307(c)(2)(A) - (H) of this title (relating to MDR of
Fee Disputes), which establishes the generally acceptable standards for
documentation.
(c) A
health care provider must include correct billing codes from the applicable
division fee guidelines in effect on the date or dates of service when
submitting medical bills.
(d) The
health care provider that provided the health care must submit its own bill,
unless:
(1) the health care was provided as
part of a return-to-work rehabilitation program in accordance with the division
fee guidelines in effect for the dates of service;
(2) the health care was provided by an
unlicensed individual under the direct supervision of a licensed health care
provider, in which case the supervising health care provider must submit the
bill;
(3) the health care provider
contracts with an agent for purposes of medical bill processing, in which case
the health care provider agent may submit the bill; or
(4) the health care provider is a pharmacy
that has contracted with a pharmacy processing agent for purposes of medical
bill processing, in which case the pharmacy processing agent may submit the
bill.
(e) A medical bill
must be submitted:
(1) for an amount that does
not exceed the health care provider's usual and customary charge for the health
care provided in accordance with Labor Code §§
413.011 and
415.005; and
(2) in the name of the licensed health care
provider that provided the health care or that provided direct supervision of
an unlicensed individual who provided the health care.
(f) Health care providers must not resubmit
medical bills to insurance carriers after the insurance carrier has taken final
action on a complete medical bill and provided an EOB except in accordance with
§
133.250 of this chapter (relating
to Reconsideration for Payment of Medical Bills).
(g) Health care providers may correct and
resubmit as a new bill an incomplete bill that has been returned by the
insurance carrier.
(h) Not later
than the 15th day after receipt of a request for additional medical
documentation, a health care provider must submit to the insurance carrier:
(1) any requested additional medical
documentation related to the charges for health care rendered; or
(2) a notice the health care provider does
not possess requested medical documentation.
(i) The health care provider must indicate on
the medical bill if documentation is submitted related to the medical
bill.
(j) The health care provider
may elect to bill the injured employee's employer if the employer has indicated
a willingness to pay the medical bill or bills. Such billing is subject to the
following:
(1) A health care provider who
elects to submit medical bills to an employer waives, for the duration of the
election period, the rights to:
(A) prompt
payment, as provided by Labor Code §
408.027;
(B) interest for delayed payment as provided
by Labor Code §
413.019; and
(C) medical dispute resolution as provided by
Labor Code §
413.031.
(2) When a health care provider
bills the employer, the health care provider must submit an information copy of
the bill to the insurance carrier, which clearly indicates that the information
copy is not a request for payment from the insurance carrier.
(3) When a health care provider bills the
employer, the health care provider must bill in accordance with the division's
fee guidelines and §
133.10 of this chapter (relating
to Required Billing Forms/Formats).
(4) A health care provider must not submit a
medical bill to an employer for charges an insurance carrier has reduced,
denied, or disputed.
(k)
A health care provider must not submit a medical bill to an injured employee
for all or part of the charge for any of the health care provided, except as an
informational copy clearly indicated on the bill, or in accordance with
subsection (l) of this section. The information copy must not request
payment.
(l) The health care
provider may only submit a bill for payment to the injured employee in
accordance with:
(1) Labor Code §
413.042;
(2) Insurance Code §
1305.451; or
(3)
§
134.504 of this title (relating to
Pharmaceutical Expenses Incurred by the Injured Employee).
(m) A designated doctor must include the
assignment number on the medical bill in accordance with §
133.10 of this title (relating to
Required Billing Forms/Formats).
(n) A designated doctor who refers the
injured employee for additional testing or evaluation under §127.10 must
provide the assignment number to the health care provider performing the
testing or evaluation. The health care provider performing the testing or
evaluation must include the assignment number on the medical bill in accordance
with §133.10.
(o) This section
is effective for medical bills submitted on or after June 1, 2024, including
medical bills submitted as a result of an examination that was ordered or
referred as the result of an order issued on or after June 1, 2024.
