Texas Administrative Code
Title 28 - INSURANCE
Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION
Chapter 42 - MEDICAL BENEFITS
Subchapter B - MEDICAL COST EVALUATION
Section 42.165 - Carrier On-Site Audit of Hospital Bills
Universal Citation: 28 TX Admin Code ยง 42.165
Current through Reg. 49, No. 38; September 20, 2024
(a) The carrier may request an on-site audit of a hospital bill.
(b) The request shall:
(1) be made in writing;
(2) be made no later than 40 days after
receipt of the bill; and
(3) be
accompanied by payment of either 75% of the bill as submitted, or a $50 audit
fee.
(c) The audit shall be conducted according to the Instructions for On-Site Audit of Hospital Charges by Workers' Compensation Carrier, hereby adopted by reference. Copies of this document will be made available upon written request to the Administrator, Medical Cost Evaluation Division, Industrial Accident Board, 200 East Riverside, First Floor, Austin, Texas 78704-1287.
(d) Every audit shall be documented on the medical audit summary sheet, which shall include the following information:
(1) claimant's name;
(2) IAB claim number;
(3) provider's name, address, and federal tax
identification number;
(4) health
care provider-reviewer's report; and
(5) for each audited item, the following:
applicable code; code description; amount billed; amount paid; and, if
appropriate, amount reduced or denied, accompanied by a sufficient explanation
for each reduction or denial.
Disclaimer: These regulations may not be the most recent version. Texas may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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