Current through Reg. 49, No. 38; September 20, 2024
(a) General. The
carrier shall promptly date stamp each health care provider bill with the date
the same was received by the carrier. Failure on the carrier's part to comply
with this rule shall create a rebuttable presumption that such health care
provider bill was received by the carrier within five business days of the date
of such bill.
(b) Time for review.
(1) General. The carrier shall complete its
review of a bill within 30 days of receipt. The review may include an audit, as
described by §
42.160
of this title (relating to Carrier Desk Audit of Bills). A bill may not be
reduced unless the carrier conducts an audit.
(2) Pharmaceutical bills. The carrier shall
complete its review of a pharmaceutical bill within 10 days of
receipt.
(3) Hospital bills;
on-site audit. If the carrier decides to conduct an on-site audit of a hospital
bill, the carrier shall proceed according to the provisions of §
42.165
of this title (relating to Carrier On-Site Audit of Hospital Bills). The time
for review shall be extended until completion of the on-site audit.
(c) Completion of review. Within
10 days of completion of the review, or, if a pharmaceutical bill, within five
days of completion of the review, the carrier shall:
(1) remit to the provider full payment of the
bill as submitted; or
(2) remit to
the provider the amount of payment the carrier has determined to be
appropriate. If the carrier remits to the provider an amount less than the
amount billed, or remits no payment, the carrier shall immediately send the
provider and the claimant or claimant's representative copies of the
appropriate medical audit summary sheet, as described in §
42.160
and §
42.165
of this title (relating to Carrier Desk Audit of Bills and Carrier On-Site
Audit of Hospital Bills). The copies sent to the provider and the claimant or
claimant's representative shall contain the following statement. "The insurance
carrier and not the claimant/patient or employer, is solely liable for all
reasonable and necessary medical treatment rendered in connection with the
injury, and no billing for any unpaid amounts should be directed to the
claimant/patient or employer, nor should any attempt be made to collect any
unpaid amount from the claimant/patient or employer, unless the claim has been
denied by the board or the court."
(d) Suspension of medical benefits. The
carrier's failure to comply with the requirements of subsection (c) of this
section within the time indicated constitutes suspension of medical benefits,
pursuant to Texas Civil Statutes, Article 8306, §18a(b).
(e) Bill reduction. Forty days after posting,
the health care provider may request assistance from the board in compelling
the carrier to file reasons for reducing a bill.
