28 Tex. Admin. Code § 133.250 - Reconsideration for Payment of Medical Bills
(a) If the health care provider is
dissatisfied with the insurance carrier's final action on a medical bill, the
health care provider may request that the insurance carrier reconsider its
action. If the health care provider is requesting reconsideration of a bill
denied based on 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) and may be submitted
orally or in writing.
(b) The
health care provider shall submit the request for reconsideration no later than
10 months from the date of service.
(c) A health care provider shall not submit a
request for reconsideration until:
(1) the
insurance carrier has taken final action on a medical bill; or
(2) the health care provider has not received
an explanation of benefits within 50 days from submitting the medical bill to
the insurance carrier.
(d) A written request for reconsideration
shall:
(1) reference the original bill and
include the same billing codes, date(s) of service, and dollar amounts as the
original bill;
(2) include a copy
of the original explanation of benefits, if received, or documentation that a
request for an explanation of benefits was submitted to the insurance
carrier;
(3) include any necessary
and related documentation not submitted with the original medical bill to
support the health care provider's position; and
(4) include a bill-specific, substantive
explanation in accordance with §
133.3 of this title (relating to
Communication Between Health Care Providers and Insurance Carriers) that
provides a rational basis to modify the previous denial or
payment.
(e) An oral
request for reconsideration must clearly identify the health care service(s)
denied based on an adverse determination and include a substantive explanation
in accordance with §
133.3 of this title that provides
a rational basis to modify the previous denial or payment. Not later than the
fifth working day after the date of receipt of the request for reconsideration,
the insurance carrier must send to the requesting party a letter acknowledging
the date of the receipt of the oral request that includes a reasonable list of
documents the requesting party is required to submit. This subsection applies
to reconsideration requests made on or after six months from the effective date
of this rule.
(f) An insurance
carrier shall review all written reconsideration requests for completeness in
accordance with subsection (d) of this section and may return an incomplete
written reconsideration request no later than seven days from the date of
receipt. A health care provider may complete and resubmit its written request
to the insurance carrier.
(g) The
insurance carrier shall take final action on a reconsideration request within
30 days of receiving the request for reconsideration. The insurance carrier
shall provide an explanation of benefits:
(1)
in accordance with §
133.240(e) - (f)
of this title (relating to Medical Payments and Denials) for all items included
in a reconsideration request in the form and format prescribed by the division
when there is a change in the original, final action; or
(h) A health care provider shall
not resubmit a request for reconsideration earlier than 35 days from the date
the insurance carrier received the original request for reconsideration or
after the insurance carrier has taken final action on the reconsideration
request.
(i) If the health care
provider is dissatisfied with the insurance carrier's final action on a medical
bill after reconsideration, 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).
(j) 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.
(k) 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 Adverse Determination) and §
19.2011 of this title, including
the requirement that prior to issuance of an adverse determination on the
request for reconsideration 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
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.