Current through Reg. 49, No. 38; September 20, 2024
(a) Definitions. The following words and
terms, when used in this subchapter, have the following meanings unless the
context clearly indicates otherwise.
(1) First
responder--As defined in Labor Code §
504.055(a).
(2) Life-threatening--A disease or condition
for which the likelihood of death is probable unless the course of the disease
or condition is interrupted, as defined in Insurance Code §
4201.002.
(3) Medical dispute resolution (MDR)--A
process for resolution of one or more of the following disputes:
(A) a medical fee dispute; or
(B) a medical necessity dispute, which may
be:
(i) a preauthorization or concurrent
medical necessity dispute; or
(ii)
a retrospective medical necessity dispute.
(4) Medical fee dispute--A dispute that
involves an amount of payment for non-network health care rendered to an
injured employee that has been determined to be medically necessary and
appropriate for treatment of that injured employee's compensable injury. The
dispute is resolved by the division pursuant to division rules, including
§
133.307 of
this title (relating to MDR of Fee Disputes). The following types of disputes
can be a medical fee dispute:
(A) a health
care provider, or a qualified pharmacy processing agent as described in Labor
Code §
413.0111,
dispute of an insurance carrier reduction or denial of a medical
bill;
(B) an injured employee
dispute of reduction or denial of a refund request for health care charges paid
by the injured employee; and
(C) a
health care provider dispute regarding the results of a 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.
(5) Network
health care--Health care delivered or arranged by a certified workers'
compensation health care network, including authorized out-of-network care, as
defined in Insurance Code Chapter 1305 and related rules.
(6) Non-network health care--Health care not
delivered or arranged by a certified workers' compensation health care network
as defined in Insurance Code Chapter 1305 and related rules. "Non-network
health care" includes health care delivered pursuant to Labor Code §
408.0281
and §
408.0284.
(7) Preauthorization or concurrent medical
necessity dispute--A dispute that involves a review of adverse determination of
network or non-network health care requiring preauthorization or concurrent
utilization review. The dispute is reviewed by an independent review
organization (IRO) pursuant to the Insurance Code, the Labor Code and related
rules, including §
133.308
of this title (relating to MDR of Medical Necessity Disputes).
(8) Requestor--The party that timely files a
request for medical dispute resolution with the division; the party seeking
relief in medical dispute resolution.
(9) Respondent--The party against whom relief
is sought.
(10) Retrospective
medical necessity dispute--A dispute that involves a review of the medical
necessity of health care already provided. The dispute is reviewed by an IRO
pursuant to the Insurance Code, Labor Code and related rules, including §
133.308
of this title.
(11) Serious bodily
injury--As defined by §
1.07, Penal
Code.
(12) State active duty--As
defined by §
437.001, Government
Code.
(13) State training and other
duty--As defined by §
437.001, Government
Code.
(14) Texas military
forces--As defined by §
437.001, Government
Code.
(b) Dispute
Sequence. If a dispute regarding compensability, extent of injury, liability,
or medical necessity exists for the same service for which there is a medical
fee dispute, the disputes regarding compensability, extent of injury,
liability, or medical necessity shall be resolved prior to the submission of a
medical fee dispute for the same services in accordance with Labor Code §
413.031
and §
408.021.
(c) Division Administrative Fee. The division
may assess a fee, as published on the division's website, in accordance with
Labor Code §
413.020 when
resolving disputes pursuant to §
133.307 and
§
133.308
of this title if the decision indicates the following:
(1) the health care provider billed an amount
in conflict with division rules, including billing rules, fee guidelines or
treatment guidelines;
(2) the
insurance carrier denied or reduced payment in conflict with division rules,
including reimbursement or audit rules, fee guidelines or treatment
guidelines;
(3) the insurance
carrier has reduced the payment based on a contracted discount rate with the
health care provider but has not made the contract or the health care provider
notice required under Labor Code §
408.0281
available upon the division's request;
(4) the insurance carrier has reduced or
denied payment based on a contract that indicates the direction or management
of health care through a health care provider arrangement that has not been
certified as a workers' compensation network, in accordance with Insurance Code
Chapter 1305 or through a health care provider arrangement authorized under
Labor Code §
504.053(b)(2);
or
(5) the insurance carrier or
healthcare provider did not comply with a provision of the Insurance Code,
Labor Code or related rules.
(d) Confidentiality. Any documentation
exchanged by the parties during MDR that contains information regarding a
patient other than the injured employee for that claim must be redacted by the
party submitting the documentation to remove any information that identifies
that patient.
(e) Severability. If
a court of competent jurisdiction holds that any provision of §§
133.305,
133.307, or
133.308
of this title is inconsistent with any statutes of this state,
unconstitutional, or invalid for any reason, the remaining provisions of these
sections remain in full effect.
(f)
Texas Military Forces. For a claim under Labor Code §
501.028, the travel of a
member of the Texas military forces to or from the member's duty location is
considered to be in the course and scope of the member's employment if the
member is:
(1) serving on state active duty
and engaged in authorized duty under written orders; or
(2) on state training and other
duty.
