Texas Administrative Code
Title 28 - INSURANCE
Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION
Chapter 140 - DISPUTE RESOLUTION-GENERAL PROVISIONS
Section 140.8 - Procedures for Health Care Insurers to Pursue Reimbursement of Medical Benefits under Labor Code Section 409.0091
Universal Citation: 28 TX Admin Code ยง 140.8
Current through Reg. 49, No. 38; September 20, 2024
(a) Applicability. This section applies only to subclaims by a health care insurer based on information received under Labor Code § 402.084(c-3).
(b) Health care insurer. "Health care insurer" means an insurance carrier and an authorized representative of an insurance carrier, as described by Labor Code § 402.084(c-1).
(c) Request to Workers' Compensation Insurance Carrier. A health care insurer seeking reimbursement must first file a reimbursement request with the workers' compensation insurance carrier.
(1) Form. The request must be in the
form/format and manner prescribed by the Division of Workers' Compensation
(Division) and must contain all the required elements listed on the
form.
(2) Notice. The health care
insurer must give notice of the request to the injured employee and the health
care provider that performed the services that are the subject of the
reimbursement request. The notice shall include a copy of the reimbursement
request and an explanation that the health care insurer is seeking
reimbursement for medical care costs.
(d) Deadlines for Response to Reimbursement Request to the Workers' Compensation Insurance Carrier.
(1) 90 Day Response Deadline. The workers'
compensation insurance carrier must respond to a reimbursement request under
this section by either paying, reducing, or denying payment in writing not
later than the 90th day after the date the reimbursement request was first
received, unless additional information is requested, pursuant to paragraph (2)
of this subsection.
(2) Request for
Additional Information. The workers' compensation insurance carrier may request
additional information from the health care insurer if there is not sufficient
information to substantiate the claim. The health care insurer has 30 days
after receiving the request for more information to provide the information
requested to the workers' compensation insurance carrier. Any request for
additional information shall be in writing, be relevant and necessary for the
resolution of the request. A workers' compensation insurance carrier shall not
be penalized, including not being held responsible for costs of obtaining the
additional information, if the workers' compensation insurance carrier denies
payment in order to move to dispute resolution to obtain additional information
to process the request. It is the health care insurer's obligation to furnish
its authorized representatives with any information necessary for the
resolution of a reimbursement request. The Division considers any medical
billing information or documentation possessed by the health care insurer or
one of its authorized representatives to be simultaneously possessed by the
health care insurer and all of its authorized representatives.
(3) 120 Day Response Deadline. If the
workers' compensation insurance carrier has requested additional information
from the health care insurer pursuant to paragraph (2) of this subsection, the
workers' compensation insurance carrier must respond in writing to the health
care insurer's reimbursement request not later than the 120th day after the
date the reimbursement request was first received, unless otherwise provided by
mutual agreement.
(e) Response to a Reimbursement Request. The workers' compensation insurance carrier must respond to a reimbursement request by either paying, reducing or denying payment.
(1) Paying or Reducing
Payment.
(A) The workers' compensation
insurance carrier shall pay the health care insurer the lesser of:
(i) the amount payable under the applicable
Division fee guideline as of the date of service; or
(ii) the actual amount paid by the health
care insurer.
(B) If No
Fee Guideline. In the absence of a Division fee guideline for a specific
service paid, the amount per service paid by the health care insurer shall be
considered in determining a fair and reasonable payment pursuant to §
134.1 of
this title (relating to Medical Reimbursement).
(C) Interest. The health care insurer may not
recover interest as a part of the payable amount.
(D) Previous Payments. The workers'
compensation insurance carrier shall reduce any reimbursable amount by any
payments the workers' compensation insurance carrier previously made to the
same health care provider for the provision of the same health care on the same
dates of service. In making such a reduction in reimbursement, the workers'
compensation insurance carrier shall provide evidence of the previous payments
made to the health care provider.
(E) Notice to Injured Employee and Health
Care Provider. The workers' compensation insurance carrier must give notice of
its response to the reimbursement request to the injured employee and the
health care provider that performed the services that are the subject of the
reimbursement request. If the claim is compensable, the notice shall include an
explanation that the claim is compensable and that the health care provider
must reimburse the injured employee for any amounts paid to the health care
provider by the injured employee.
(F) The health care provider may submit a
reimbursement request to the workers' compensation insurance carrier for any
money owed under Division fee guidelines for the medical services rendered on a
compensable claim and is entitled to dispute resolution under §
133.307 of
this title (relating to MDR of Fee Disputes). The workers' compensation
insurance carrier is liable for full payment in accordance with Division fee
guidelines and applicable rules for the medical services rendered on a
compensable claim.
(2)
Explanation of Benefits. The workers' compensation insurance carrier must
provide the health care insurer, all health care providers, and the injured
employee an explanation of benefits (EOB) in the form and manner prescribed by
the Division. The EOB must provide sufficient explanation regarding the basis
for a denial of the reimbursement request.
(f) Reimbursement of Injured Employee. If the injured employee's medical care costs are reimbursable under Title 5 of the Labor Code, a health care provider must refund to the injured employee any payments made by the injured employee to the health care provider, including but not limited to, copays and deductibles. Reimbursement must be made within 45 days of receipt of the notice that the claim is compensable.
(g) Filing Notice of Subclaimant Status.
(1) 120 Day Deadline. A health care insurer
must file a written notice of subclaimant status with the Division not later
than the 120th day after a workers' compensation insurance carrier fails to
respond to a health care insurer's reimbursement request or reduces or denies
the requested reimbursement amount.
(2) Location for Filing Notice. The notice
may be filed with the Division of Workers' Compensation at any local Division
field office or at the Division's central office in Austin, Texas.
(3) One Injured Employee Per Notice. A health
care insurer must file separate notices for each individual injured employee in
which the health care insurer seeks subclaimant status.
(4) One Notice Per Injured Employee Date of
Injury. If an individual injured employee has multiple claims based on
different dates of injury, the health care insurer must file a separate notice
for each date of injury for which medical benefits were provided.
(5) Form. The notice of subclaimant status
must be in the form and manner prescribed by the Division.
(h) Request for Dispute Resolution. The rules applicable to dispute resolution vary according to the reason for denial of reimbursement. Disputes regarding extent of injury, liability, or medical necessity must be resolved prior to pursuing a medical fee dispute. A request for medical dispute resolution may be filed in lieu of a request for subclaimant status, and shall be considered a request for subclaimant status for purposes of this section.
(1) Claim or
Treatment Not Compensable.
(A) A health care
insurer must file a request for a benefit review conference pursuant to §
141.1
of this title (relating to Requesting and Setting a Benefit Review Conference)
with the Division not later than the 120th day after a workers' compensation
insurance carrier reduces or denies the requested reimbursement amount based on
compensability or extent of injury issues.
(B) The health care insurer may pursue
dispute resolution to obtain an order from an administrative law judge
regarding compensability or eligibility for benefits in accordance with Labor
Code Chapter 410 and applicable Division rules.
(C) A subclaim dispute based on a denial of
reimbursement due to compensability or extent of injury is subject to dispute
resolution pursuant to Chapters 140 - 143 of this title (relating to Dispute
Resolution).
(2) Lack of
Medical Necessity.
(A) A health care insurer
must file a request for medical dispute resolution with the workers'
compensation insurance carrier or the insurance carrier's utilization review
agent not later than the 120th day after a workers' compensation insurance
carrier reduces or denies the requested reimbursement amount due to lack of
medical necessity.
(B) A medical
dispute based on the workers' compensation insurance carrier's denial of a
health care insurer's reimbursement request due to lack of medical necessity is
subject to dispute resolution pursuant to §
133.308
of this title (relating to MDR of Medical Necessity Disputes).
(C) A subclaimant shall follow the
independent review process allowed for a non-network health care provider
seeking retrospective review of a service under that section, with any
modifications specified by this subsection.
(D) A request for reconsideration is not
required prior to a request for independent review, notwithstanding the
requirements for requesting independent review under §
133.308
of this title.
(E) A request for
independent review may be filed, notwithstanding the timeliness requirements
for filing a request for independent review under §
133.308
of this title.
(F) Notwithstanding
the provisions of §
133.308
of this title, regarding independent review organization requests for
additional information, if a health care provider is requested to submit
records, the health care insurer shall reimburse the health care provider copy
expenses for the requested records.
(3) Reduction, Denial or Failure to Respond.
(A) A health care insurer must file a request
for medical dispute resolution with the Division not later than:
(i) the 120th day after a workers'
compensation insurance carrier fails to respond to a health care insurer's
reimbursement request or reduces or denies the requested reimbursement amount
for reasons other than lack of medical necessity; or
(ii) 60 days after the date the requestor
receives the final decision, inclusive of all appeals, on compensability or
extent of injury issues raised in accordance with this subsection.
(B) A medical dispute based on the
workers' compensation insurance carrier's failure to respond to a health care
insurer's reimbursement request or the result of a reduction or denial of the
requested reimbursement amount for reasons other than those listed in paragraph
(1) or (2) of this subsection is subject to medical dispute resolution pursuant
to §
133.307 of
this title, notwithstanding the definition of medical fee dispute in §
133.305 of
this title (relating to MDR--General), and the health care insurer must follow
the medical fee dispute resolution process allowed for a health care provider
under that section, with any modifications specified by this
subsection.
(C) Notwithstanding the
requirements of §
133.307(c)(2)
of this title, a health care insurer shall only be required to include with a
request for medical fee dispute resolution, a copy of the health care insurer
reimbursement request as originally submitted to the workers' compensation
insurance carrier, a copy of the EOB relevant to the fee dispute received from
the workers' compensation insurance carrier, and sufficient information to
substantiate the claim.
(D) A
request for reconsideration is not required prior to a request for medical fee
dispute resolution, notwithstanding the requirements for requesting medical fee
dispute resolution under §
133.307 of
this title.
(E) A request for
medical fee dispute resolution may be filed, notwithstanding the timeliness
requirements for filing a request for medical fee dispute resolution under
§
133.307 of
this title.
(i) Multiple Entities Seeking Reimbursement for Same Services. If there are multiple entities seeking reimbursement for the same services and dates of services for the same health care insurer for the same injured employee, the following apply:
(1) When the workers'
compensation insurance carrier obtains a release from the health care insurer
indicating that those specific services have been paid in full, no other entity
may collect for those specific services.
(2) If a dispute remains over the fees to be
paid for those specific services, the first in time to file a dispute with the
Division is the only subclaimant that has a right to dispute resolution, and
reimbursement, for that injured employee's claim and those specific services
rendered unless that subclaimant abandons the dispute resolution process prior
to a final adjudication of the issues.
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