|(a) Definitions. The following words and terms, when
used in this subchapter, have the following meanings unless the context
clearly indicates otherwise.
(1) Adverse determination--A determination by a utilization
review agent that the health care services furnished or proposed to
be furnished to a patient are not medically necessary, as defined
in Insurance Code §4201.002.
(2) First responder--As defined in Labor Code §504.055(a).
(3) Life-threatening--A disease or condition for which
the likelihood of death is probable unless the course of the disease
or condition is interrupted, as defined in Insurance Code §4201.002.
(4) Medical dispute resolution (MDR)--A process for
resolution of one or more of the following disputes:
(A) a medical fee dispute; or
(B) a medical necessity dispute, which may be:
(i) a preauthorization or concurrent medical necessity
(ii) a retrospective medical necessity dispute.
(5) Medical fee dispute--A dispute that involves an
amount of payment for non-network health care rendered to an injured
employee that has been determined to be medically necessary and appropriate
for treatment of that injured employee's compensable injury. The dispute
is resolved by the division pursuant to division rules, including §133.307
of this title (relating to MDR of Fee Disputes). The following types
of disputes can be a medical fee dispute:
(A) a health care provider, or a qualified pharmacy
processing agent as described in Labor Code §413.0111, dispute
of an insurance carrier reduction or denial of a medical bill;
(B) an injured employee dispute of reduction or denial
of a refund request for health care charges paid by the injured employee;
(C) a health care provider dispute regarding the results
of a division or insurance carrier audit or review which requires
the health care provider to refund an amount for health care services
previously paid by the insurance carrier.
(6) Network health care--Health care delivered or arranged
by a certified workers' compensation health care network, including
authorized out-of-network care, as defined in Insurance Code Chapter
1305 and related rules.
(7) Non-network health care--Health care not delivered
or arranged by a certified workers' compensation health care network
as defined in Insurance Code Chapter 1305 and related rules. "Non-network
health care" includes health care delivered pursuant to Labor Code §413.011(d-1)
(8) Preauthorization or concurrent medical necessity
dispute--A dispute that involves a review of adverse determination
of network or non-network health care requiring preauthorization or
concurrent review. The dispute is reviewed by an independent review
organization (IRO) pursuant to the Insurance Code, the Labor Code
and related rules, including §133.308 of this title (relating
to MDR by Independent Review Organizations).
(9) Requestor--The party that timely files a request
for medical dispute resolution with the division; the party seeking
relief in medical dispute resolution.
(10) Respondent--The party against whom relief is sought.
(11) Retrospective medical necessity dispute--A dispute
that involves a review of the medical necessity of health care already
provided. The dispute is reviewed by an IRO pursuant to the Insurance
Code, Labor Code and related rules, including §133.308 of this
(12) Serious bodily injury--As defined by §1.07,
(b) Dispute Sequence. If a dispute regarding compensability,
extent of injury, liability, or medical necessity exists for the same
service for which there is a medical fee dispute, the disputes regarding
compensability, extent of injury, liability, or medical necessity
shall be resolved prior to the submission of a medical fee dispute
for the same services in accordance with Labor Code §413.031
(c) Division Administrative Fee. The division may assess
a fee, as published on the division's website, in accordance with
Labor Code §413.020 when resolving disputes pursuant to §133.307
and §133.308 of this title if the decision indicates the following:
(1) the health care provider billed an amount in conflict
with division rules, including billing rules, fee guidelines or treatment
(2) the insurance carrier denied or reduced payment
in conflict with division rules, including reimbursement or audit
rules, fee guidelines or treatment guidelines;
(3) the insurance carrier has reduced the payment based
on a contracted discount rate with the health care provider but has
not made the contract or the health care provider notice required
under Labor Code §408.0281 available upon the division's request;
(4) the insurance carrier has reduced or denied payment
based on a contract that indicates the direction or management of
health care through a health care provider arrangement that has not
been certified as a workers' compensation network, in accordance with
Insurance Code Chapter 1305 or through a health care provider arrangement
authorized under Labor Code §504.053(b)(2); or
(5) the insurance carrier or healthcare provider did
not comply with a provision of the Insurance Code, Labor Code or related
(d) Confidentiality. Any documentation exchanged by
the parties during MDR that contains information regarding a patient
other than the injured employee for that claim must be redacted by
the party submitting the documentation to remove any information that
identifies that patient.
(e) Severability. If a court of competent jurisdiction
holds that any provision of §§133.305, 133.307, or 133.308
of this title is inconsistent with any statutes of this state, unconstitutional,
or invalid for any reason, the remaining provisions of these sections
remain in full effect.
(f) This section is effective July 1, 2012.
|Source Note: The provisions of this §133.305 adopted to be effective December 31, 2006, 31 TexReg 10314; amended to be effective May 25, 2008, 33 TexReg 3954; amended to be effective July 1, 2012, 37 TexReg 2408