Current through Reg. 49, No. 38; September 20, 2024
(a)
Applicability of this rule is as follows:
(1)
This section applies to professional dental services provided in the Texas
Workers' Compensation system.
(2)
This section shall be applicable to professional dental services provided on or
after June 15, 2005. For professional dental services provided August 1, 2003
through June 14, 2005, §134.202
of this title (relating to Medical Fee Guideline) shall be applicable. For
professional dental services provided December 1, 1996 through July 31, 2003,
§134.302
of this title (relating to Dental Fee Guideline) shall be applicable.
(3) Specific provisions contained in the
Texas Workers' Compensation Act (the Act), or Texas Workers' Compensation
Commission (commission) rules, including this rule, shall take precedence over
any provision adopted by or utilized by Texas Medicaid in administering the
Texas Medicaid Dental Fee Schedule. Independent Review Organization (IRO)
decisions regarding medical necessity are made on a case-by-case basis. The
commission will monitor IRO decisions to determine whether commission
rulemaking action would be appropriate.
(4) Whenever a component of the Texas
Medicaid Dental Fee Schedule is revised and effective, use of the revised
component shall be required for compliance with commission rules, decisions and
orders for services rendered on or after the effective date of the revised
component.
(b) For
coding, billing, reporting, and reimbursement of dental treatments and
services, Texas Workers' Compensation system participants shall apply the Texas
Medicaid Dental Fee Schedule in effect on the date a service is provided with
any additions or exceptions in this section.
(c) To determine the maximum allowable
reimbursements (MARs), the following apply:
(1) The fees listed for the procedure codes
in the Texas Medicaid Dental Fee Schedule shall be multiplied by
200%.
(2) For products and services
for which the Texas Medicaid Dental Fee Schedule does not establish a value,
the carrier shall assign a relative value, which may be based on nationally
recognized published relative value studies, published commission medical
dispute decisions, and values assigned for services involving similar work and
resource commitments.
(d) Reimbursement for dental laboratory
procedures is bundled with the maximum fees for the associated dental
procedures. No additional reimbursement shall be due.
(e) In all cases, reimbursement shall be the
lesser of the:
(1) MAR amount;
(2) health care provider's usual and
customary charge; or
(3) workers'
compensation negotiated and/or contracted amount that applies to the billed
service(s).
