(a) Disability management is a process designed to optimize health care and return to work outcomes for injured employees to avoid delayed recovery in the Texas Workers’ Compensation System.
(b) This chapter is designed to provide disability management tools, such as treatment and return to work guidelines, treatment protocols, treatment planning, and case management to benchmark, manage, and achieve improved outcomes. The Division may use these tools for the following purposes, including, but not limited to:
(1) resolving income benefit disputes;
(2) resolving medical benefit disputes;
(3) establishing performance-based tiers;
(4) defining performance-based incentives;
(5) determining sanctions or penalties;
(6) performing medical quality reviews; or
(7) assessing other matters deemed appropriate by the Commissioner of Workers’ Compensation.
(c) The Division will utilize this chapter to implement and interpret specific provisions contained in Labor Code § 413.011(a) and (e), and this chapter takes precedence over any conflicting payment policy provisions adopted or utilized by the Centers for Medicare and Medicaid Services (CMS) in administering the Medicare program.
(d) Independent Review Organization (IRO) decisions regarding medical necessity made in accordance with Labor Code § 413.031 and § 133.308 of this title (relating to Medical Dispute Resolution by Independent Review Organizations), which are made on a case-by-case basis, take precedence in that case only, over adopted treatment guidelines, treatment protocols, treatment planning and Medicare payment policies.
The provisions of this § 137.1 adopted to be effective January 18, 2007, 32 TexReg 163.