453-99-1809-m4

ORDER GRANTING PLEA IN JURISDICTION The Texas Workers’ Compensation Commission filed a Plea in Jurisdiction seeking Summary Dispositions in the above cases. The cases were consolidated into one hearing with five other cases involving the same parties and similar facts, but the Plea in Jurisdiction involves only the two cases numbered above. The entire group of seven cases was referred to mediation but no settlement was reached and the hearing on the plea and the merits of the cases was held on December 21, 2001. The record closed on January 25, 2002. The Fund argued that the Commission has jurisdiction

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453-03-2920-m5

DECISION AND ORDER Injured worker________[1] (Claimant) has appealed a decision of the Medical Review Division (MRD) of the Texas Workers= Compensation Commission (the Commission) denying reimbursement of $323.00 she paid for immunotherapy and intradermal skin tests provided to her from June 15, 2001, through September 7, 2001, by her treating physician. The MRD=s denial of payment was based on its review of a decision made by an independent review organization (IRO) physician who found the disputed treatment was not medically necessary to treat Claimant=s compensable injury. As set out below, the Administrative Law Judge (ALJ) finds Claimant did not substantiate

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453-02-0935-m4

DECISION AND ORDER I. Background and Procedural History The Clinic for Special Surgery (the Clinic or Petitioner) is an ambulatory surgical center (ASC). Patient ____ was treated at the Clinic with an epidural steroid injection. The Clinic submitted a bill for $2,840.48 to Hartford Fire Insurance (Hartford) for services rendered to___ Hartford paid the Clinic $2,236.00. The Clinic requested dispute resolution. The Medical Review Division (MRD) of the Texas Worker’s Compensation Commission (Commission) declined to order additional payment, and the Petitioner appealed the decision. The rate of reimbursement for ASCs is in dispute because the Commission does not currently have

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454-15-1876-m4-np

DECISION AND ORDER Zurich American Insurance Co. (Carrier) appeals the approval of full reimbursement to Texas Health Fort Worth (Provider) for services provided to an injured worker because the Provider released the injured worker to a rehabilitation facility rather than home. The Administrative Law Judge (ALJ) concludes that under the Inpatient Hospital Fee Guideline (Guideline), the Provider was not entitled to additional reimbursement and is entitled to only $30,914.83. I.I. JURISDICTION, NOTICE, AND PROCEDURAL HISTORY There are no issues of notice or jurisdiction in this proceeding. Therefore, these matters are addressed in the Findings of Fact and Conclusions of Law

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454-13-2363-m4

DECISION AND ORDER Parker City Pharmacy (Provider) seeks reimbursement of $3,269.55 from Continental Casualty Insurance Company (Carrier) for prescription medications it dispensed to an injured worker (Claimant) on December 27, 2004, and January 24, 2005. The Administrative Law Judge (ALJ) finds the Provider is not entitled to reimbursement. I.JURISDICTION, NOTICE, AND PROCEDURAL HISTORY There are no issues of notice or jurisdiction. Therefore, these matters are addressed in the Findings of Fact and Conclusions of Law without discussion here. On August 22, 2005, Provider filed a request for medical fee dispute resolution with the Medical Review Division (MRD) of the Texas

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454-12-1946-m4

DECISION AND ORDER ____ (Claimant) challenges the denial of reimbursement by ______ (______) for services provided to an injured worker. The Administrative Law Judge (ALJ) concludes that Claimant did not timely file a request for medical fee dispute resolution. Consequently, Claimant is not entitled to reimbursement. I.JURISDICTION, NOTICE, AND PROCEDURAL HISTORY There are no disputed issues of notice or jurisdiction. Therefore, those matters are set out in the Findings of Fact and Conclusions of Law without further discussion here. Claimant filed a request for medical fee dispute resolution with the Texas Department of Insurance, Division of Workers’ Compensation (Division) on

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