28 Tex. Admin. Code § 133.240 - Medical Payments and Denials
(a) An insurance
carrier shall take final action after conducting bill review on a complete
medical bill, or determine to audit the medical bill in accordance with §
133.230 of this chapter (relating
to Insurance Carrier Audit of a Medical Bill), not later than the 45th day
after the date the insurance carrier received a complete medical bill. An
insurance carrier's deadline to make or deny payment on a bill is not extended
as a result of a pending request for additional documentation.
(b) For health care provided to injured
employees not subject to a workers' compensation health care network
established under Insurance Code Chapter 1305, the insurance carrier shall not
deny reimbursement based on medical necessity for health care preauthorized or
voluntarily certified under Chapter 134 of this title (relating to
Benefits--Guidelines for Medical Services, Charges, and Payments). For
pharmaceutical services provided to any injured employee, the insurance carrier
shall not deny reimbursement based on medical necessity for pharmaceutical
services preauthorized or agreed to under Chapter 134, Subchapter F of this
title (relating to Pharmaceutical Benefits).
(c) The insurance carrier shall not change a
billing code on a medical bill or reimburse health care at another billing
code's value.
(d) The insurance
carrier may request additional documentation, in accordance with §
133.210 of this title (relating to
Medical Documentation), not later than the 45th day after receipt of the
medical bill to clarify the health care provider's charges.
(e) The insurance carrier shall send the
explanation of benefits in accordance with the elements required by §
133.500 and §
133.501 of this title (relating to
Electronic Formats for Electronic Medical Bill Processing and Electronic
Medical Bill Processing, respectively) if the insurance carrier submits the
explanation of benefits in the form of an electronic remittance. The insurance
carrier shall send an explanation of benefits in accordance with subsection (f)
of this section if the insurance carrier submits the explanation of benefits in
paper form. The explanation of benefits shall be sent to:
(1) the health care provider when the
insurance carrier makes payment or denies payment on a medical bill;
and
(2) the injured employee when
payment is denied because:
(A) of an adverse
determination;
(B) the health care
was provided by a health care provider other than:
(i) the treating doctor selected in
accordance with Labor Code §
408.022;
(ii) a health care provider that the treating
doctor has chosen as a consulting or referral health care provider;
(iii) a doctor performing a required medical
examination in accordance with §
126.5 of this title (relating to
Entitlement and Procedure for Requesting Required Medical Examinations) and §
126.6 of this title (relating to
Required Medical Examination);
(iv)
a doctor performing a designated doctor examination in accordance with Labor
Code §
408.0041;
or
(C) the health care
was unrelated to the compensable injury, in accordance with §
124.2 of this title (relating to
Carrier Reporting and Notification Requirements).
(3) the prescribing doctor, if different from
the health care provider identified in paragraph (1) of this subsection, when
payment is denied for pharmaceutical services because of any reason relating to
the compensability of, liability for, extent of, or relatedness to the
compensable injury, or for reasons relating to the reasonableness or medical
necessity of the pharmaceutical services.
(f) The paper form of an explanation of
benefits under subsection (e) of this section, §
133.250 of this title (relating to
Reconsideration for Payment of Medical Bills), or §
133.260 of this title (relating to
Refunds) shall include the following elements:
(1) division claim number, if
known;
(2) insurance carrier claim
number;
(3) injured employee's
name;
(4) last four digits of
injured employee's social security number;
(5) date of injury;
(6) health care provider's name and
address;
(7) health care provider's
federal tax ID or national provider identifier if the health care provider's
federal tax ID is the same as the health care provider's social security
number;
(8) patient control number
if included on the submitted medical bill;
(9) insurance carrier's name and
address;
(10) insurance carrier
control number;
(11) date of bill
review/refund request;
(12)
diagnosis code(s);
(13) name and
address of company performing bill review;
(14) name and telephone number of bill review
contact;
(15) workers' compensation
health care network name (if applicable);
(16) pharmacy, durable medical equipment, or
home health care services informal or voluntary network name (if applicable)
pursuant to Labor Code §
408.0281 and §
408.0284;
(17) health care service information for each
billed health care service, to include:
(A)
date of service;
(B) the CPT,
HCPCS, NDC, or other applicable product or service code;
(C) CPT, HCPCS, NDC, or other applicable
product or service code description;
(D) amount charged;
(E) unit(s) of service;
(F) amount paid;
(G) adjustment reason code that conforms to
the standards described in §
133.500 and §
133.501 of this title if total
amount paid does not equal total amount charged;
(H) explanation of the reason for
reduction/denial if the adjustment reason code was included under subparagraph
(G) of this paragraph and if applicable;
(18) a statement that contains the following
text: "Health care providers shall not bill any unpaid amounts to the injured
employee or the employer, or make any attempt to collect the unpaid amount from
the injured employee or the employer unless the injury is finally adjudicated
not to be compensable, or the insurance carrier is relieved of the liability
under Labor Code §
408.024. However, pursuant
to §
133.250 of this title, the health
care provider may file an appeal with the insurance carrier if the health care
provider disagrees with the insurance carrier's determination";
(19) if the insurance carrier is requesting a
refund, the refund amount being requested and an explanation of why the refund
is being requested; and
(20) if the
insurance carrier is paying interest in accordance with §
134.130 of this title (relating to
Interest for Late Payment on Medical Bills and Refunds), the interest amount
paid through use of an unspecified product or service code and the number of
days on which interest was calculated by using a unit per
day.
(g) When the
insurance carrier pays a health care provider for health care for which the
division has not established a maximum allowable reimbursement, the insurance
carrier shall explain and document the method it used to calculate the payment
in accordance with §
134.1 of this title (relating to
Medical Reimbursement) or §
134.503 of this title (relating to
Pharmacy Fee Guideline).
(h) An
insurance carrier shall have filed, or shall concurrently file, the applicable
notice required by Labor Code §
409.021, and §
124.2 and §
124.3 of this title (relating to
Investigation of an Injury and Notice of Denial/Dispute) if the insurance
carrier reduces or denies payment for health care provided based solely on the
insurance carrier's belief that:
(1) the
injury is not compensable;
(2) the
insurance carrier is not liable for the injury due to lack of insurance
coverage; or
(3) the condition for
which the health care was provided was not related to the compensable
injury.
(i) If
dissatisfied with the insurance carrier's final action, the health care
provider may request reconsideration of the bill in accordance with §
133.250 of this title.
(j) If the health care provider is requesting
reconsideration of an adverse determination, the request for reconsideration
constitutes an appeal for the purposes of §
19.2011 of this title (relating to
Written Procedures for Appeal of Adverse Determinations). If dissatisfied with
the reconsideration outcome, the health care provider may request medical
dispute resolution in accordance with the provisions of Chapter 133, Subchapter
D of this title (relating to Dispute of Medical Bills).
(k) Health care providers, injured employees,
employers, attorneys, and other participants in the system shall not resubmit
medical bills to insurance carriers after the insurance carrier has taken final
action on a complete medical bill and provided an explanation of benefits
except as provided in §133.250 and Chapter 133, Subchapter D of this
title.
(l) All payments of medical
bills that an insurance carrier makes on or after the 60th day after the date
the insurance carrier originally received the complete medical bill shall
include interest calculated in accordance with §
134.130 of this title without any
action taken by the division. The interest payment shall be paid at the same
time as the medical bill payment.
(m) Except as provided by Insurance Code §
1305.153, when an
insurance carrier remits payment to a health care provider agent, the agent
shall remit to the health care provider the full amount that the insurance
carrier reimburses. If the insurance carrier remits payment under Insurance
Code §
1305.153, then the
payment must be made in accordance with that section.
(n) When an insurance carrier remits payment
to a pharmacy processing agent, the pharmacy processing agent's reimbursement
from the insurance carrier shall be made in accordance with §
134.503 of this title. The
pharmacy's reimbursement shall be made in accordance with the terms of its
contract with the pharmacy processing agent.
(o) An insurance carrier commits an
administrative violation if the insurance carrier fails to pay, reduce, deny,
or notify the health care provider of the intent to audit a medical bill in
accordance with Labor Code §
408.027 and division
rules.
(p) For the purposes of this
section, all utilization review must be performed by an insurance carrier that
is registered with or a utilization review agent that is certified by the Texas
Department of Insurance to perform utilization review in accordance with
Insurance Code Chapter 4201 and Chapter 19 of this title.
(1) All utilization review agents or
registered insurance carriers who perform utilization review under this section
must comply with Labor Code §
504.055 and any other
provisions of Chapter 19, Subchapter U of this title (relating to Utilization
Reviews for Health Care Provided under Workers' Compensation Insurance
Coverage) that relate to the expedited provision of medical benefits to first
responders employed by political subdivisions who sustain a serious bodily
injury in the course and scope of employment.
(2) In accordance with Labor Code §
501.028(b),
an insurance carrier must accelerate and give priority to a claim for medical
benefits:
(A) by a member of the Texas
military forces who,
(i) while on state active
duty,
(ii) sustains a serious
bodily injury, as defined by Penal Code §
1.07;
(B) including all health care required to
cure or relieve the effects naturally resulting from a compensable
injury.
(q)
When denying payment due to an adverse determination under this section, the
insurance carrier shall comply with the requirements of §
19.2009 of this title (relating to
Notice of Determinations Made in Utilization Review). Additionally, in any
instance where the insurance carrier is questioning the medical necessity or
appropriateness of the health care services, the insurance carrier shall comply
with the requirements of §
19.2010 of this title (relating to
Requirements Prior to Issuing Adverse Determination), including the requirement
that prior to issuance of an adverse determination the insurance carrier shall
afford the health care provider a reasonable opportunity to discuss the billed
health care with a doctor or, in cases of a dental plan or chiropractic
services, with a dentist or chiropractor, respectively.
Notes
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