28 Tex. Admin. Code § 133.306 - Interlocutory Orders for Medical Benefits
(a) The Commissioner of Workers' Compensation
may delegate the authority to issue interlocutory orders for accrued and/or
future medical benefits to division staff.
(b) The division may enter an interlocutory
order for accrued or future medical benefits when:
(1) the division determines that an insurance
carrier has disputed medical benefits as the result of a liability,
compensability, or extent of injury dispute that an insurance carrier has
raised in accordance with §
124.2 of this title (relating to
Carrier Reporting and Notification Requirements), and the division determines
that those medical benefits are or were medically necessary and constitute
health care reasonably required and are not subject to the medical dispute
resolution process set forth in Chapter 133, Subchapter D of this title
(relating to Dispute of Medical Bills);
(2) at the conclusion of the medical dispute
resolution process:
(A) the division
determines that an insurance carrier has disputed medical benefits as the
result of a liability, compensability, or extent of injury dispute that an
insurance carrier has raised in accordance with §
124.2 of this title, and the
division deems that the disputed medical benefits are or were medically
necessary and constitute health care reasonably required; or
(B) the division determines that future
medical benefits for which preauthorization is required are medically necessary
and constitute health care reasonably required; or
(3) an insurance carrier makes an adverse
determination for drugs prescribed on or after September 1, 2011 and excluded
from the division's closed formulary as set forth in §§
134.510,
134.530,
134.540, and
134.550 of this title (relating to
Requirements for the Transition to the Use of the Closed Formulary for Claims
with Dates of Injury Prior to September 1, 2011, Requirements for Use of the
Closed Formulary for Claims Not Subject to Certified Networks, Requirements for
Use of the Closed Formulary for Claims Subject to Certified Networks, and
Medical Interlocutory Order respectively) and the division determines that
those medical benefits are or were medically necessary and constitute health
care reasonably required.
(c) Absent the interlocutory order as set
forth in subsections (a) and (b) of this section, the division shall enter an
interlocutory order only when the injured employee would not receive medical
benefits that are medically necessary and constitute health care reasonably
required.
(d) A party shall comply
with an interlocutory order entered in accordance with this section on the
earlier of the seventh day after receipt of the order or the date the division
establishes in the body of the order.
(e) The insurance carrier may dispute an
interlocutory order entered under this title by filing a written request for a
hearing in accordance with Labor Code §
413.055 and §
148.3 of this title (relating to
Requesting a Hearing).
(f) An
insurance carrier that makes an overpayment pursuant to an interlocutory order
may be eligible for reimbursement from the Subsequent Injury Fund. An insurance
carrier must make a request for reimbursement in accordance with §
116.11 of this title (relating to
Request for Reimbursement from the Subsequent Injury Fund).
Notes
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