(a) Definitions. The following words and terms, when used in this subchapter, have the following meanings unless the context clearly indicates otherwise.
(1) First responder–As defined in Labor Code § 504.055(a).
(2) 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.
(3) 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 dispute; or
(ii) a retrospective medical necessity dispute.
(4) 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; and
(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.
(5) 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.
(6) 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 § 408.0281 and § 408.0284.
(7) 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 utilization 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 of Medical Necessity Disputes).
(8) Requestor–The party that timely files a request for medical dispute resolution with the division; the party seeking relief in medical dispute resolution.
(9) Respondent–The party against whom relief is sought.
(10) 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 title.
(11) Serious bodily injury–As defined by § 1.07, Penal Code.
(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 and § 408.021.
(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 guidelines;
(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 rules.
(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.
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; amended to be effective March 30, 2014, 39 TexReg 2095.