Texas Administrative Code
Title 28 - INSURANCE
Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION
Chapter 133 - GENERAL MEDICAL PROVISIONS
Subchapter D - DISPUTE OF MEDICAL BILLS
Section 133.306 - Interlocutory Orders for Medical Benefits

Universal Citation: 28 TX Admin Code ยง 133.306

Current through Reg. 49, No. 38; September 20, 2024

(a) The Commissioner of Workers' Compensation may delegate the authority to issue interlocutory orders for accrued and/or future medical benefits to division staff.

(b) The division may enter an interlocutory order for accrued or future medical benefits when:

(1) the division determines that an insurance carrier has disputed medical benefits as the result of a liability, compensability, or extent of injury dispute that an insurance carrier has raised in accordance with § 124.2 of this title (relating to Carrier Reporting and Notification Requirements), and the division determines that those medical benefits are or were medically necessary and constitute health care reasonably required and are not subject to the medical dispute resolution process set forth in Chapter 133, Subchapter D of this title (relating to Dispute of Medical Bills);

(2) at the conclusion of the medical dispute resolution process:
(A) the division determines that an insurance carrier has disputed medical benefits as the result of a liability, compensability, or extent of injury dispute that an insurance carrier has raised in accordance with § 124.2 of this title, and the division deems that the disputed medical benefits are or were medically necessary and constitute health care reasonably required; or

(B) the division determines that future medical benefits for which preauthorization is required are medically necessary and constitute health care reasonably required; or

(3) an insurance carrier makes an adverse determination for drugs prescribed on or after September 1, 2011 and excluded from the division's closed formulary as set forth in §§ 134.510, 134.530, 134.540, and 134.550 of this title (relating to Requirements for the Transition to the Use of the Closed Formulary for Claims with Dates of Injury Prior to September 1, 2011, Requirements for Use of the Closed Formulary for Claims Not Subject to Certified Networks, Requirements for Use of the Closed Formulary for Claims Subject to Certified Networks, and Medical Interlocutory Order respectively) and the division determines that those medical benefits are or were medically necessary and constitute health care reasonably required.

(c) Absent the interlocutory order as set forth in subsections (a) and (b) of this section, the division shall enter an interlocutory order only when the injured employee would not receive medical benefits that are medically necessary and constitute health care reasonably required.

(d) A party shall comply with an interlocutory order entered in accordance with this section on the earlier of the seventh day after receipt of the order or the date the division establishes in the body of the order.

(e) The insurance carrier may dispute an interlocutory order entered under this title by filing a written request for a hearing in accordance with Labor Code § 413.055 and § 148.3 of this title (relating to Requesting a Hearing).

(f) An insurance carrier that makes an overpayment pursuant to an interlocutory order may be eligible for reimbursement from the Subsequent Injury Fund. An insurance carrier must make a request for reimbursement in accordance with § 116.11 of this title (relating to Request for Reimbursement from the Subsequent Injury Fund).

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