(a) “Maximum allowable reimbursement” (MAR), when used in this chapter, is defined as the maximum amount payable to a health care provider in the absence of a contractual fee arrangement that is consistent with § 413.011 of the Labor Code, and Division rules.
(b) Medical reimbursement for health care services provided to injured employees subject to a workers’ compensation health care network established under Insurance Code Chapter 1305 shall be made in accordance with the provisions of Insurance Code Chapter 1305, except as provided in subsections (c) and (d) of this section.
(c) Examinations conducted pursuant to Labor Code §§ 408.004, 408.0041, and 408.151 shall be reimbursed in accordance with § 134.204 of this chapter (relating to Medical Fee Guideline for Workers’ Compensation Specific Services).
(e) Medical reimbursement for health care not provided through a workers’ compensation health care network shall be made in accordance with:
(1) the Division’s fee guidelines;
(2) a negotiated contract; or
(3) in the absence of an applicable fee guideline or a negotiated contract, a fair and reasonable reimbursement amount as specified in subsection (f) of this section.
(f) Fair and reasonable reimbursement shall:
(1) be consistent with the criteria of Labor Code § 413.011;
(2) ensure that similar procedures provided in similar circumstances receive similar reimbursement; and
(3) be based on nationally recognized published studies, published Division medical dispute decisions, and/or values assigned for services involving similar work and resource commitments, if available.
(g) The insurance carrier shall consistently apply fair and reasonable reimbursement amounts and maintain, in reproducible format, documentation of the insurance carrier’s methodology(ies) establishing fair and reasonable reimbursement amounts. Upon request of the Division, an insurance carrier shall provide copies of such documentation.
The provisions of this § 134.1 adopted to be effective May 2, 2006, 31 TexReg 3561; amended to be effective March 1, 2008, 33 TexReg 364.