Texas Workers' Compensation

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§ 42.15. Definitions

The following words and terms, when used in this part, shall have the following meanings, unless the context clearly indicates otherwise.

(1) Accrual of medical benefits–The right to medical benefits for a compensable injury accrues as of the date of injury and continues for the life of the injured worker, or until terminated by agreement between the injured worker and the carrier, and is limited in amount only according to the reasonableness of the expense and the necessity of the treatment.

(2) Act–Texas Civil Statutes, Articles 8306-8309(i).

(3) Association–See carrier.

(4) Billing by report–The billing procedure to be used by a health care provider when:

(A) no procedural definition and/or dollar value is established in the board’s fee guidelines for the treatment or service rendered; or

(B) when the provider determines that the procedural definition and/or dollar value established in the fee guidelines does not adequately describe the treatment or service rendered. (See § 42.145 of this title (relating to Billing.))

(5) Board–The Industrial Accident Board of the State of Texas.

(6) Carrier–Shall be synonymous with “association,” as defined in Texas Civil Statutes, Article 8309, § 1, to mean any insurance company or entity authorized to insure payment of workers’ compensation, including political subdivisions, the State of Texas, the University of Texas, Texas A&M University, and the State Department of Highways and Public Transportation.

(7) Carrier review and audit of individual provider’s bills–

(A) Carrier review of individual provider’s bill–A careful screening of a bill, as submitted, with minimal supporting medical documentation. Attention is given to relation of date of accident to date of treatment; relation of treatment to injury; proper itemization; correct/appropriate coding; duplicate charges; correct addition; and compliance with fee and utilization guidelines. May result in audit. Performed at the office of the carrier or carrier-audit representative.

(B) Carrier audit of individual provider’s bill–A detailed, line-by-line examination of billed charges, comparing charges to services rendered, using maximum medical documentation such as daily PT, and progress and/or clinic notes. Performed at the office of the carrier or carrier-audit representative. Also known as a desk audit.

(8) Carrier review and audit of hospital bills–

(A) Carrier review of hospital’s bill–A careful, selective screening of a hospital bill, as submitted, with minimal supporting medical documentation. Attention is given to correct/appropriate coding; computer errors; duplicate charges; potential unrelated charges; and compliance with fee and utilization guidelines. May result in audit. Performed at the office of the carrier or carrier-audit representative.

(B) Carrier audit of hospital’s bill–A line-by-line examination of billed charges, comparing the doctor’s orders with supporting medical documentation in the patient’s chart. Performed either at the office of the carrier or carrier-audit representative (desk audit) or at the hospital (on-site audit).

(9) Claimant–The worker or health care provider making a claim. The health care provider may be a derivative or independent claimant.

(10) Compensable injury–Any injury having to do with and originating in the work, business, trade, or profession of the subscriber, received by an employee while engaged in or about the furtherance of the affairs or business of the subscriber, either upon the subscriber’s premises or elsewhere.

(11) Consulting doctor–A licensed doctor who examines a worker, or the worker’s medical record, at the request of the treating doctor to aid in diagnosis and/or treatment, and who may, at the request of the treating doctor, provide specialized treatment of the compensable injury or illness.

(12) Doctor–A licensed practitioner of medicine, osteopathy, chiropractic, or podiatry.

(13) Health care provider (provider)–A health care provider is:

(A) a doctor or other person duly licensed to practice one or more of the healing arts within the limits of the license of the licentiate;

(B) a health facility; and

(C) an entity providing health care which is covered under the Act.

(14) Health facility–A health facility is:

(A) a general or specialty hospital providing inpatient and outpatient services, whether licensed by the Texas Department of Health or the Texas Department of Mental Health and Mental Retardation;

(B) an outpatient surgery center not covered by a hospital’s license, other than a physician’s office, and licensed by the Texas Department of Health; and

(C) an outpatient imaging center not covered by a hospital’s license, other than a physician’s office, which provides radiographic, computerized tomography, magnetic resonance imaging, or other diagnostic imaging services.

(15) Independent medical exam–See medical exam order.

(16) Injured worker’s representative–Any person designated in writing by the injured worker to assist him or her in pursuing a claim for compensation.

(17) Liability for medical services–This is the sole responsibility of the carrier prior to final disposition of a claim to pay fair and reasonable charges for necessary medical services rendered to an injured worker. This is the responsibility of the injured worker:

(A) after final disposition of a claim for services that are not related to the compensable injury;

(B) for services not related to the compensable injury; and

(C) for services rendered after the liability of the carrier has been terminated.

(18) Maximum medical recovery–Exists when no further improvement in the injured worker’s health is reasonably expected from additional medical treatment or the passage of time.

(19) Medical exam order (also known as independent medical exam)–An order of the board requiring a claimant to present him or herself to be examined by a physician or chiropractor. The board may enter a medical exam order either on its own motion, or at the carrier’s request. The claimant has the right to have his or her doctor present during a carrier-requested examination, the cost of which shall be borne by the carrier.

(20) Medical report–A board-approved form or narrative letter that transmits medical information. Reports must include all relevant information.

(21) Small rural hospital–A general hospital licensed for less than 100 beds which is located in a county classified as rural by the Health Care Financing Administration for purposes of Medicare reimbursement.

(22) Subscriber–Any employer who has obtained workers’ compensation insurance coverage. This includes all political subdivisions, the State of Texas, the University of Texas, Texas A&M University, and the State Department of Highways and Public Transportation.

(23) Treating doctor–A doctor who is primarily responsible for the treatment of a worker’s compensable injury or illness.

The provisions of this § 42.15 adopted to be effective October 20, 1988, 13 TexReg 4990; amended to be effective May 11, 1989, 14 TexReg 2082.

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At a Glance:

Title:

§ 42.15. Definitions

Title:

Title 28. Insurance

Status:

Current

Usage:

Old Law Rule

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