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Retrospective Medical Necessity
March 7, 2020
DECISION AND ORDER This case is a dispute over whether National Union Fire Insurance Company of Pittsburgh Pa. (Carrier) should pay a claim filed by Back & Joint Clinic (Clinic) for services performed on an injured worker (Claimant) from June 19, 1999, through February 2, 2000. The Texas Workers’ Compensation Commission (Commission) Medical Review Division (MRD) ordered the Carrier to pay $7,896.00. This decision concludes that the Carrier should pay for the majority of the...

Medical Fees
June 24, 2019
DECISION AND ORDER I. INTRODUCTION Various hospitals (Providers) requested hearings on decisions by the Medical Review Division (MRD) of the Texas Department of Insurance, Division of Workers’ Compensation (Division)[1] denying additional reimbursement to Providers under the Stop-Loss Exception for a hospital stay provided to an injured worker. Providers argued that reimbursement for the admission should be based on the Stop-Loss Exception to the per diem reimbursement methodology contained in the 1997 Acute Care Inpatient Hospital...

Medical Fees
December 7, 2018
DECISION AND ORDER This case involves a dispute regarding payment for medical services provided by Healthcare Provider (HCP)covered by the worker’s compensation insurance system. The Texas Department of Insurance’s Division of Worker’s Compensation (Division) conducted a medical fee dispute resolution (MFDR) and declined to order Carrier to reimburse HCP amount of $276.03. The Administrative Law Judge (ALJ) concludes that HCP is not entitled to this additional reimbursement from Carrier for medical services because HCP failed...

Medical Fees
November 26, 2018
SOAH DOCKET NO. 454-18-2743.M4-NP MRD NO. _________________ CARRIER, Petitioner v. HEALTHCARE PROVIDER, Respondent § § § § § § § BEFORE THE STATE OFFICE OF ADMINISTRATIVE HEARINGS DECISION AND ORDER Carrier challenges a decision of the Texas Department of Insurance, Division of Worker’s Compensation (Division) that awarded Healthcare Provider (HCP) reimbursement for a combination of several drugs compounded into a topical cream. Carrier appeared at the hearing and presented evidence in support of its position...

Medical Fees
November 2, 2018
DECISION AND ORDER Carrier challenges a decision of the Texas Department of Insurance, Division of Workers’ Compensation (Division) that awarded Healthcare Provider (HCP) a $1,688.74 reimbursement for a compound topical cream prepared by HCP. Carrier argued that because the compound cream was not a drug approved by the Food and Drug Administration (FDA), it required preauthorization. The Administrative Law Judge (ALJ) concludes HCP is not entitled to reimbursement because preauthorization was not obtained. I.JURISDICTION, NOTICE,...

Medical Fees
October 29, 2018
DECISION AND ORDER This case involves a dispute regarding payment for medical services provided by Healthcare Provider (HCP) to an injured employee (Claimant) covered by the worker’s compensation insurance system. The Texas Department of Insurance’s Division of Worker’s Compensation (Division) conducted a medical fee dispute resolution (MFDR) and declined to order Carrier to reimburse HCP in the amount of $162,628.70.[1] HCP contends it is entitled to this additional reimbursement. The Administrative Law Judge (ALJ) concludes...

Medical Fees
October 3, 2018
DECISION AND ORDER Carrier challenges the Medical Fee Dispute Findings and Decision (MFD Decision) issued by the Texas Department of Insurance, Division of Workers’ Compensation (Division). The MFD Decision ordered Carrier to reimburse Healthcare Provider (Provider) the additional sum of $4,579.70 for implantables used by Provider during outpatient surgery performed on an injured worker (Claimant). The Administrative Law Judge (ALJ) concludes that the MFD Decision is correct and that Carrier owes Provider the additional sum...

Medical Fees
August 3, 2018
SOAH DOCKET NO. 454-18-2555.M4-NP MFDR NO. _________________ HEALTHCARE PROVIDER, Petitioner v. CARRIER, Respondent § § § § § § § BEFORE THE STATE OFFICE OF ADMINISTRATIVE HEARINGS MODIFIED DECISION AND ORDER FOLLOWING GRANT OF MOTION FOR REHEARING This case involves urine drug testing ordered by Healthcare Provider (HCP) for an injured employee covered by the workers’ compensation insurance system. The Texas Department of Insurance’s Division of Workers’ Compensation (Division) conducted medical fee dispute resolution (MFDR)...

Medical Fees
June 15, 2018
DECISION AND ORDER This case involves services rendered by Health Care Provider(HCP) to an injured person covered by the workers’ compensation insurance system. The Texas Department of Insurance’s Division of Workers’ Compensation (Division) conducted medical fee dispute resolution (MFDR) and Carrier to reimburse HCP in the amount of $335.48.[1] HCP contends it is entitled to an additional reimbursement of $817.60. The Administrative Law Judge (ALJ) concludes that no additional payment is due. I.JURISDICTION, NOTICE, AND...

Medical Fees
April 3, 2018
DECISION AND ORDER This case involves services rendered by (Healthcare Provider) (HCP) to an injured employee covered by the workers’ compensation insurance system. The Texas Department of Insurance’s Division of Workers’ Compensation (Division) conducted medical fee dispute resolution (MFDR) and declined to order (Carrier) to reimburse (HCP) in the amount of $13,905.00.[1] The Administrative Law Judge (ALJ) concludes that (HCP) is not entitled to additional reimbursement. I.JURISDICTION, NOTICE, AND PROCEDURAL HISTORY There are no issues...

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