(a) Applicability of this rule is as follows:
(1) This section applies to professional dental services provided in the Texas Workers’ Compensation system.
(2) This section shall be applicable to professional dental services provided on or after June 15, 2005. For professional dental services provided August 1, 2003 through June 14, 2005, § 134.202 of this title (relating to Medical Fee Guideline) shall be applicable. For professional dental services provided December 1, 1996 through July 31, 2003, § 134.302 of this title (relating to Dental Fee Guideline) shall be applicable.
(3) Specific provisions contained in the Texas Workers’ Compensation Act (the Act), or Texas Workers’ Compensation Commission (commission) rules, including this rule, shall take precedence over any provision adopted by or utilized by Texas Medicaid in administering the Texas Medicaid Dental Fee Schedule. Independent Review Organization (IRO) decisions regarding medical necessity are made on a case-by-case basis. The commission will monitor IRO decisions to determine whether commission rulemaking action would be appropriate.
(4) Whenever a component of the Texas Medicaid Dental Fee Schedule is revised and effective, use of the revised component shall be required for compliance with commission rules, decisions and orders for services rendered on or after the effective date of the revised component.
(b) For coding, billing, reporting, and reimbursement of dental treatments and services, Texas Workers’ Compensation system participants shall apply the Texas Medicaid Dental Fee Schedule in effect on the date a service is provided with any additions or exceptions in this section.
(c) To determine the maximum allowable reimbursements (MARs), the following apply:
(1) The fees listed for the procedure codes in the Texas Medicaid Dental Fee Schedule shall be multiplied by 200%.
(2) For products and services for which the Texas Medicaid Dental Fee Schedule does not establish a value, the carrier shall assign a relative value, which may be based on nationally recognized published relative value studies, published commission medical dispute decisions, and values assigned for services involving similar work and resource commitments.
(d) Reimbursement for dental laboratory procedures is bundled with the maximum fees for the associated dental procedures. No additional reimbursement shall be due.
(e) In all cases, reimbursement shall be the lesser of the:
(1) MAR amount;
(2) health care provider’s usual and customary charge; or
(3) workers’ compensation negotiated and/or contracted amount that applies to the billed service(s).
The provisions of this § 134.303 adopted to be effective June 9, 2005, 30 TexReg 3232.