28 Tex. Admin. Code § 134.1 - Medical Reimbursement
(a) "Maximum
allowable reimbursement" (MAR), when used in this chapter, is defined as the
maximum amount payable to a health care provider in the absence of a
contractual fee arrangement that is consistent with §
413.011 of the Labor Code,
and Division rules.
(b) Medical
reimbursement for health care services provided to injured employees subject to
a workers' compensation health care network established under Insurance Code
Chapter 1305 shall be made in accordance with the provisions of Insurance Code
Chapter 1305, except as provided in subsections (c) and (d) of this
section.
(c) Examinations conducted
pursuant to Labor Code §§
408.004,
408.0041, and
408.151 shall be
reimbursed in accordance with §
134.204 of this chapter (relating
to Medical Fee Guideline for Workers' Compensation Specific
Services).
(d) Examinations
conducted pursuant to Labor Code §
408.0042 shall be
reimbursed in accordance with §
126.14 of this title (relating to
Treating Doctor Examination to Define the Compensable Injury).
(e) Medical reimbursement for health care not
provided through a workers' compensation health care network shall be made in
accordance with:
(1) the Division's fee
guidelines;
(2) a negotiated
contract; or
(3) in the absence of
an applicable fee guideline or a negotiated contract, a fair and reasonable
reimbursement amount as specified in subsection (f) of this section.
(f) Fair and reasonable
reimbursement shall:
(1) be consistent with
the criteria of Labor Code §
413.011;
(2) ensure that similar procedures provided
in similar circumstances receive similar reimbursement; and
(3) be based on nationally recognized
published studies, published Division medical dispute decisions, and/or values
assigned for services involving similar work and resource commitments, if
available.
(g) The
insurance carrier shall consistently apply fair and reasonable reimbursement
amounts and maintain, in reproducible format, documentation of the insurance
carrier's methodology(ies) establishing fair and reasonable reimbursement
amounts. Upon request of the Division, an insurance carrier shall provide
copies of such documentation.
Notes
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