reglab/statecodes huggingface dataset:
2023 Texas Statutes › Labor Code › Title 5 - Workers' Compensation › Subtitle A - Texas Workers' Compensation Act › Chapter 413 - Medical Review › Subchapter B. Medical Services and Fees › Section 413.012. Medical Policy and Guideline Updates Required

Sec. 413.012.  MEDICAL POLICY AND GUIDELINE UPDATES REQUIRED.  The medical policies and fee guidelines shall be reviewed and revised at least every two years to reflect fair and reasonable fees and to reflect medical treatment or ranges of treatment that are reasonable or necessary at the time the review and revision is conducted.
Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993.
2023 Texas Statutes › Labor Code › Title 5 - Workers' Compensation › Subtitle A - Texas Workers' Compensation Act › Chapter 413 - Medical Review › Subchapter B. Medical Services and Fees › Section 413.013. Programs

Sec. 413.013.  PROGRAMS.  The commissioner by rule shall establish:
(1)  a program for prospective, concurrent, and retrospective review and resolution of a dispute regarding health care treatments and services;
(2)  a program for the systematic monitoring of the necessity of treatments administered and fees charged and paid for medical treatments or services, including the authorization of prospective, concurrent, or retrospective review under the medical policies of the division to ensure that the medical policies or guidelines are not exceeded;
(3)  a program to detect practices and patterns by insurance carriers in unreasonably denying authorization of payment for medical services requested or performed if authorization is required by the medical policies of the division; and
(4)  a program to increase the intensity of review for compliance with the medical policies or fee guidelines for any health care provider that has established a practice or pattern in charges and treatments inconsistent with the medical policies and fee guidelines.
Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993.
Amended by:
Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 3.235, eff. September 1, 2005.
2023 Texas Statutes › Labor Code › Title 5 - Workers' Compensation › Subtitle A - Texas Workers' Compensation Act › Chapter 413 - Medical Review › Subchapter B. Medical Services and Fees › Section 413.0141. Initial Pharmaceutical Coverage

Sec. 413.0141.  INITIAL PHARMACEUTICAL COVERAGE.  The commissioner may by rule provide that an insurance carrier shall provide for payment of specified pharmaceutical services sufficient for the first seven days following the date of injury if the health care provider requests and receives verification of insurance coverage and a verbal confirmation of an injury from the employer or from the insurance carrier as provided by Section 413.014.  The rules adopted by the commissioner shall provide that an insurance carrier is eligible for reimbursement for pharmaceutical services paid under this section from the subsequent injury fund in the event the injury is determined not to be compensable.
Added by Acts 2001, 77th Leg., ch. 1456, Sec. 4.03, eff. June 17, 2001.
Amended by:
Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 3.237, eff. September 1, 2005.
2023 Texas Statutes › Labor Code › Title 5 - Workers' Compensation › Subtitle A - Texas Workers' Compensation Act › Chapter 413 - Medical Review › Subchapter B. Medical Services and Fees › Section 413.015. Payment by Insurance Carriers; Audit and Review

Sec. 413.015.  PAYMENT BY INSURANCE CARRIERS;  AUDIT AND REVIEW.  (a)  Insurance carriers shall make appropriate payment of charges for medical services provided under this subtitle.  An insurance carrier may contract with a separate entity to forward payments for medical services.  Any payment due the insurance carrier from the separate entity must be made in accordance with the contract.  The separate entity is subject to the direction of the insurance carrier, and the insurance carrier is responsible for the actions of the separate entity under this subsection.
(b)  The commissioner shall provide by rule for the review and audit of the payment by insurance carriers of charges for medical services provided under this subtitle to ensure compliance of health care providers and insurance carriers with the medical policies and fee guidelines adopted by the commissioner.
(c)  The rules must require the insurance carrier to pay the expenses of the review and audit.
Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993.  Amended by Acts 2001, 77th Leg., ch. 1456, Sec. 6.03, eff. June 17, 2001.
Amended by:
Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 3.238, eff. September 1, 2005.
2023 Texas Statutes › Labor Code › Title 5 - Workers' Compensation › Subtitle A - Texas Workers' Compensation Act › Chapter 413 - Medical Review › Subchapter B. Medical Services and Fees › Section 413.016. Payments in Violation of Medical Policies and Fee Guidelines

Sec. 413.016.  PAYMENTS IN VIOLATION OF MEDICAL POLICIES AND FEE GUIDELINES.  (a)  The division shall order a refund of charges paid to a health care provider in excess of those allowed by the medical policies or fee guidelines.  The division shall also refer the health care provider alleged to have violated this subtitle to the division of compliance and practices.
(b)  If the division determines that an insurance carrier has paid medical charges that are inconsistent with the medical policies or fee guidelines adopted by the commissioner, the division shall investigate the potential violation.  If the insurance carrier reduced a charge of a health care provider that was within the guidelines, the insurance carrier shall be directed to submit the difference to the provider unless the reduction is in accordance with an agreement between the health care provider and the insurance carrier.
Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993.
Amended by:
Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 3.239, eff. September 1, 2005.
2023 Texas Statutes › Labor Code › Title 5 - Workers' Compensation › Subtitle A - Texas Workers' Compensation Act › Chapter 413 - Medical Review › Subchapter B. Medical Services and Fees › Section 413.017. Presumption of Reasonableness

Sec. 413.017.  PRESUMPTION OF REASONABLENESS.  The following medical services are presumed reasonable:
(1)  medical services consistent with the medical policies and fee guidelines adopted by the commissioner; and
(2)  medical services that are provided subject to prospective, concurrent, or retrospective review as required by the medical policies of the division and that are authorized by an insurance carrier.
Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993.
Amended by:
Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 3.240, eff. September 1, 2005.
2023 Texas Statutes › Labor Code › Title 5 - Workers' Compensation › Subtitle A - Texas Workers' Compensation Act › Chapter 413 - Medical Review › Subchapter B. Medical Services and Fees › Section 413.018. Review of Medical Care if Guidelines Exceeded

Sec. 413.018.  REVIEW OF MEDICAL CARE IF GUIDELINES EXCEEDED.  (a)  The commissioner by rule shall provide for the periodic review of medical care provided in claims in which guidelines for expected or average return to work time frames are exceeded.
(b)  The division shall review the medical treatment provided in a claim that exceeds the guidelines and may take appropriate action to ensure that necessary and reasonable care is provided.
(c)  The division shall implement a program to encourage employers and treating doctors to discuss the availability of modified duty to encourage the safe and more timely return to work of injured employees.  The division may require a treating or examining doctor, on the request of the employer, insurance carrier, or division, to provide a functional capacity evaluation of an injured employee and to determine the employee's ability to engage in physical activities found in the workplace or in activities that are required in a modified duty setting.
(d)  The division shall provide through the division's health and safety information and medical review outreach programs information to employers regarding effective return to work programs.  This section does not require an employer to provide modified duty or an employee to accept a modified duty assignment.  An employee who does not accept an employer's offer of modified duty determined by the division to be a bona fide job offer is subject to Section 408.103(e).
(e)  The commissioner may adopt rules and forms as necessary to implement this section.
Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993.  Amended by Acts 1999, 76th Leg., ch. 956, Sec. 3, eff. Sept. 1, 1999.
Amended by:
Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 3.241, eff. September 1, 2005.
2023 Texas Statutes › Labor Code › Title 5 - Workers' Compensation › Subtitle A - Texas Workers' Compensation Act › Chapter 413 - Medical Review › Subchapter B. Medical Services and Fees › Section 413.019. Interest Earned for Delayed Payment, Refund, or Overpayment

Sec. 413.019.  INTEREST EARNED FOR DELAYED PAYMENT, REFUND, OR OVERPAYMENT.  (a)  Interest on an unpaid fee or charge that is consistent with the fee guidelines accrues at the rate provided by Section 401.023 beginning on the 60th day after the date the health care provider submits the bill to an insurance carrier until the date the bill is paid.
(b)  Interest on a refund from a health care provider accrues at the rate provided by Section 401.023 beginning on the 60th day after the date the provider receives notice of alleged overpayment from the insurance carrier until the date the refund is paid.
Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993.
2023 Texas Statutes › Labor Code › Title 5 - Workers' Compensation › Subtitle A - Texas Workers' Compensation Act › Chapter 413 - Medical Review › Subchapter B. Medical Services and Fees › Section 413.020. Division Charges

Sec. 413.020.  DIVISION CHARGES.  The commissioner by rule shall establish procedures to enable the division to charge:
(1)  an insurance carrier a reasonable fee for access to or evaluation of health care treatment, fees, or charges under this subtitle; and
(2)  a health care provider who exceeds a fee or utilization guideline established under this subtitle or an insurance carrier who unreasonably disputes charges that are consistent with a fee or utilization guideline established under this subtitle a reasonable fee for review of health care treatment, fees, or charges under this subtitle.
Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993.
Amended by:
Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 3.242, eff. September 1, 2005.
2023 Texas Statutes › Labor Code › Title 5 - Workers' Compensation › Subtitle A - Texas Workers' Compensation Act › Chapter 413 - Medical Review › Subchapter B. Medical Services and Fees › Section 413.023. Information to Employers

Sec. 413.023.  INFORMATION TO EMPLOYERS.  (a)  The division shall provide employers with information on methods to enhance the ability of an injured employee to return to work.  The information may include access to available research and best practice information regarding return-to-work programs for employers.
(b)  The division shall augment return-to-work program information provided to employers to include information regarding methods for an employer to appropriately assist an injured employee to obtain access to doctors who:
(1)  provide high-quality care; and
(2)  use effective occupational medicine treatment practices that lead to returning employees to productive work.
(c)  The information provided to employers under this section must help to foster:
(1)  effective working relationships with local doctors and with insurance carriers or workers' compensation health care networks certified under Chapter 1305, Insurance Code, to improve return-to-work communication; and
(2)  access to return-to-work coordination services provided by insurance carriers.
(d)  The division shall develop and make available the information described by this section.
Added by Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 3.244, eff. September 1, 2005.
2023 Texas Statutes › Labor Code › Title 5 - Workers' Compensation › Subtitle A - Texas Workers' Compensation Act › Chapter 413 - Medical Review › Subchapter B. Medical Services and Fees › Section 413.024. Information to Employees

Sec. 413.024.  INFORMATION TO EMPLOYEES.  The division shall provide injured employees with information regarding the benefits of early return to work.  The information must include information on how to receive assistance in accessing high-quality medical care through the workers' compensation system.
Added by Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 3.244, eff. September 1, 2005.
2023 Texas Statutes › Labor Code › Title 5 - Workers' Compensation › Subtitle A - Texas Workers' Compensation Act › Chapter 413 - Medical Review › Subchapter B. Medical Services and Fees › Section 413.025. Return-to-Work Goals and Assistance

Sec. 413.025.  RETURN-TO-WORK GOALS AND ASSISTANCE.  (a)  The division shall assist recipients of income benefits to return to the workforce.  The division shall develop improved data sharing, within the standards of federal privacy requirements, with all appropriate state agencies and workforce programs to inform the division of changes needed to assist income benefit recipients to successfully reenter the workforce.
(b)  The division shall train staff dealing with income benefits to respond to questions and assist injured employees in their effort to return to the workforce.  If the division determines that an injured employee is unable to ever return to the workforce, the division shall inform the employee of possible eligibility for other forms of benefits, such as social security disability income benefits.
(c)  As necessary to implement the requirements of this section, the division shall:
(1)  attempt to remove any barriers to successful employment that are identified at the division, the Texas Workforce Commission, the Department of Assistive and Rehabilitative Services, and private vocational rehabilitation programs;
(2)  ensure that data is tracked among the division, the Texas Workforce Commission, the Department of Assistive and Rehabilitative Services, and insurance carriers, including outcome data;
(3)  establish a mechanism to refer income benefit recipients to the Texas Workforce Commission and local workforce development centers for employment opportunities; and
(4)  develop a mechanism to promote employment success that includes post-referral contacts by the division with income benefit recipients.
Added by Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 3.244, eff. September 1, 2005.
2023 Texas Statutes › Labor Code › Title 5 - Workers' Compensation › Subtitle A - Texas Workers' Compensation Act › Chapter 413 - Medical Review › Subchapter C. Dispute Resolution › Section 413.0311. Review of Medical Necessity Disputes; Contested Case Hearing

Sec. 413.0311.  REVIEW OF MEDICAL NECESSITY DISPUTES; CONTESTED CASE HEARING.  (a)  This section applies only to  an appeal of an independent review organization decision regarding determination of the medical necessity for a health care service.
(b)  A party to a medical dispute described by Subsection (a) is entitled to a contested case hearing.  A contested case hearing under this section shall be conducted by an administrative law judge in the manner provided for contested case hearings under Subchapter D, Chapter 410.  Notwithstanding Section 410.024, a benefit review conference is not a prerequisite to a contested case hearing under this section.
(c)  The decision of an administrative law judge under this section is final in the absence of a timely appeal by a party for judicial review under Subsection (d).
(d)  A party who has exhausted all administrative remedies under Section 413.031 and this section and who is aggrieved by a final decision of the administrative law judge under Subsection (c) may seek judicial review of the decision.  Judicial review under this subsection shall be conducted in the manner provided for judicial review of a contested case under Subchapter G, Chapter 2001, Government Code, except that the party seeking judicial review under this section must file suit not later than the 45th day after the date on which the division mailed the party the decision of the administrative law judge.  For purposes of this subsection, the mailing date is considered to be the fifth day after the date the decision of the administrative law judge was filed with the division.
(e)  The division and the department are not considered to be parties to the medical dispute for purposes of this section.
Added by Acts 2007, 80th Leg., R.S., Ch. 1007 (H.B. 724), Sec. 2, eff. September 1, 2007.
Amended by:
Acts 2011, 82nd Leg., R.S., Ch. 1066 (S.B. 809), Sec. 3, eff. September 1, 2011.
Acts 2011, 82nd Leg., R.S., Ch. 1162 (H.B. 2605), Sec. 19, eff. September 1, 2011.
Acts 2011, 82nd Leg., R.S., Ch. 1162 (H.B. 2605), Sec. 20, eff. September 1, 2011.
Acts 2017, 85th Leg., R.S., Ch. 839 (H.B. 2111), Sec. 16, eff. September 1, 2017.
2023 Texas Statutes › Labor Code › Title 5 - Workers' Compensation › Subtitle A - Texas Workers' Compensation Act › Chapter 413 - Medical Review › Subchapter C. Dispute Resolution › Section 413.032. Independent Review Organization Decision; Appeal

Sec. 413.032.  INDEPENDENT REVIEW ORGANIZATION DECISION; APPEAL.  (a)  An independent review organization that conducts a review under this chapter shall specify the elements on which the decision of the organization is based.  At a minimum, the decision must include:
(1)  a list of all medical records and other documents reviewed by the organization;
(2)  a description and the source of the screening criteria or clinical basis used in making the decision;
(3)  an analysis of and explanation for the decision, including the findings and conclusions used to support the decision; and
(4)  a description of the qualifications of each physician or other health care provider who reviews the decision.
(b)  The independent review organization shall certify that each physician or other health care provider who reviews the decision certifies that no known conflicts of interest exist between that provider and the injured employee, the injured employee's employer, the injured employee's insurance carrier, the utilization review agent, or any of the treating doctors or insurance carrier health care providers who reviewed the case for decision before referral to the independent review organization.
Added by Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 3.247, eff. September 1, 2005.
2023 Texas Statutes › Labor Code › Title 5 - Workers' Compensation › Subtitle A - Texas Workers' Compensation Act › Chapter 413 - Medical Review › Subchapter D. Health Care Providers › Section 413.041. Disclosure

Sec. 413.041.  DISCLOSURE.  (a)  Each health care practitioner shall disclose to the division the identity of any health care provider in which the health care practitioner, or the health care provider that employs the health care practitioner, has a financial interest.  The health care practitioner shall make the disclosure in the manner provided by commissioner rule.
(b)  The commissioner shall require by rule that a doctor disclose financial interests in other health care providers as a condition of registration for the approved doctor list established under Section 408.023 and shall define "financial interest" for purposes of this section as provided by analogous federal regulations.  The commissioner by rule shall adopt the federal standards that prohibit the payment or acceptance of payment in exchange for health care referrals relating to fraud, abuse, and antikickbacks.
(c)  A health care provider that fails to comply with this section is subject to penalties and sanctions as provided by this subtitle, including forfeiture of the right to reimbursement for services rendered during the period of noncompliance.
(d)  The division shall publish all final disclosure enforcement orders issued under this section on the division's Internet website.
Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993.  Amended by Acts 2001, 77th Leg., ch. 1456, Sec. 6.05, eff. June 17, 2001.
Amended by:
Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 3.246, eff. September 1, 2005.
2023 Texas Statutes › Labor Code › Title 5 - Workers' Compensation › Subtitle A - Texas Workers' Compensation Act › Chapter 413 - Medical Review › Subchapter D. Health Care Providers › Section 413.042. Private Claims; Administrative Violation

Sec. 413.042.  PRIVATE CLAIMS;  ADMINISTRATIVE VIOLATION.  (a)  A health care provider may not pursue a private claim against a workers' compensation claimant for all or part of the cost of a health care service provided to the claimant by the provider unless:
(1)  the injury is finally adjudicated not compensable under this subtitle;  or
(2)  the employee violates Section 408.022 relating to the selection of a doctor and the doctor did not know of the violation at the time the services were rendered.
(b)  A health care provider commits an administrative violation if the provider violates Subsection (a).
Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993.
Amended by:
Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 3.248, eff. September 1, 2005.
2023 Texas Statutes › Labor Code › Title 5 - Workers' Compensation › Subtitle A - Texas Workers' Compensation Act › Chapter 413 - Medical Review › Subchapter D. Health Care Providers › Section 413.043. Overcharging Prohibited; Offense

Sec. 413.043.  OVERCHARGING PROHIBITED;  OFFENSE.  (a)  A health care provider commits an offense if the person knowingly charges an insurance carrier an amount greater than that normally charged for similar treatment to a payor outside the workers' compensation system, except for mandated or negotiated charges.
(b)  An offense under this section is a Class A misdemeanor.
Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993.
2023 Texas Statutes › Labor Code › Title 5 - Workers' Compensation › Subtitle A - Texas Workers' Compensation Act › Chapter 413 - Medical Review › Subchapter D. Health Care Providers › Section 413.044. Sanctions on Designated Doctor

Sec. 413.044.  SANCTIONS ON DESIGNATED DOCTOR.  (a)  In addition to or in lieu of an administrative penalty under Section 415.021 or a sanction imposed under Section 415.023, the commissioner may impose sanctions against a person who serves as a designated doctor under Chapter 408 who, after an evaluation conducted under Section 413.002(b), is determined by the division to be out of compliance with this subtitle or with rules adopted by the commissioner relating to:
(1)  medical policies, fee guidelines, and impairment ratings; or
(2)  the quality of decisions made under Section 408.0041 or Section 408.122.
(b)  Sanctions imposed under Subsection (a) may include:
(1)  revocation of certification for a designated doctor on the division list of designated doctors; or
(2)  restrictions on the reviews made by the person as a designated doctor.
Added by Acts 1995, 74th Leg., ch. 980, Sec. 1.44, eff. Sept. 1, 1995.
Amended by:
Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 3.249, eff. September 1, 2005.
Acts 2011, 82nd Leg., R.S., Ch. 1162 (H.B. 2605), Sec. 22, eff. September 1, 2011.
2023 Texas Statutes › Labor Code › Title 5 - Workers' Compensation › Subtitle A - Texas Workers' Compensation Act › Chapter 413 - Medical Review › Subchapter E. Implementation of Commission Powers and Duties › Section 413.051. Contracts With Review Organizations and Health Care Providers

Sec. 413.051.  CONTRACTS WITH REVIEW ORGANIZATIONS AND HEALTH CARE PROVIDERS.  (a)  In this section, "health care provider professional review organization" includes an independent review organization.
(b)  The division may contract with a health care provider, health care provider professional review organization, or other entity to develop, maintain, or review medical policies or fee guidelines or to review compliance with the medical policies or fee guidelines.
(c)  For purposes of review or resolution of a dispute as to compliance with the medical policies or fee guidelines, the division may contract with a health care provider, health care provider professional review organization, or other entity that includes in the review process health care practitioners who are licensed in the category under review and are of the same field or specialty as the category under review.
(d)  The division may contract with a health care provider, health care provider professional review organization, or other entity for medical consultant services, including:
(1)  independent medical examinations;
(2)  medical case reviews; or
(3)  establishment of medical policies and fee guidelines.
(e)  The commissioner shall establish standards for contracts under this section.
Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993.  Amended by Acts 2001, 77th Leg., ch. 1456, Sec. 1.02, eff. June 17, 2001.
Amended by:
Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 3.250, eff. September 1, 2005.
2023 Texas Statutes › Labor Code › Title 5 - Workers' Compensation › Subtitle A - Texas Workers' Compensation Act › Chapter 413 - Medical Review › Subchapter E. Implementation of Commission Powers and Duties › Section 413.0511. Medical Advisor

Sec. 413.0511.  MEDICAL ADVISOR.  (a)  The division shall employ or contract with a medical advisor, who must be a doctor as that term is defined by Section 401.011.
(b)  The medical advisor shall make recommendations regarding the adoption of rules and policies to:
(1)  develop, maintain, and review guidelines as provided by Section 413.011, including rules regarding impairment ratings;
(2)  review compliance with those guidelines;
(3)  regulate or perform other acts related to medical benefits as required by the commissioner;
(4)  impose sanctions or delete doctors from the division's list of approved doctors under Section 408.023 for:
(A)  any reason described by Section 408.0231; or
(B)  noncompliance with commissioner rules;
(5)  impose conditions or restrictions as authorized by Section 408.0231(f);
(6)  receive, and share with the medical quality review panel established under Section 413.0512, confidential information, and other information to which access is otherwise restricted by law, as provided by Sections 413.0512, 413.0513, and 413.0514 from the Texas State Board of Medical Examiners, the Texas Board of Chiropractic Examiners, or other occupational licensing boards regarding a physician, chiropractor, or other type of doctor who applies for registration or is registered with the division on the list of approved doctors;
(7)  determine minimal modifications to the reimbursement methodology and model used by the Medicare system as necessary to meet occupational injury requirements; and
(8)  monitor the quality and timeliness of decisions made by designated doctors and independent review organizations, and the imposition of sanctions regarding those decisions.
Added by Acts 2001, 77th Leg., ch. 1456, Sec. 1.02, eff. June 17, 2001.  Amended by Acts 2003, 78th Leg., ch. 963, Sec. 1, eff. June 20, 2003.
Amended by:
Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 3.251, eff. September 1, 2005.
2023 Texas Statutes › Labor Code › Title 5 - Workers' Compensation › Subtitle A - Texas Workers' Compensation Act › Chapter 413 - Medical Review › Subchapter E. Implementation of Commission Powers and Duties › Section 413.05115. Medical Quality Review Process

Sec. 413.05115.  MEDICAL QUALITY REVIEW PROCESS.  (a)  The division shall develop, and the commissioner shall adopt, criteria concerning the medical case review process under this subchapter.  In developing the criteria, and before adopting the criteria, the division and the commissioner, as applicable, must consult with the medical advisor and seek input from potentially affected parties, including health care providers and insurance carriers.
(b)  The criteria developed and adopted under this section must establish a clear process or processes:
(1)  for handling complaint-based medical case reviews; and
(2)  through which the division selects health care providers or other entities for a compliance audit or review.
(c)  The division shall make the criteria developed and adopted under this section available on the Internet website maintained by the division.
Added by Acts 2011, 82nd Leg., R.S., Ch. 1162 (H.B. 2605), Sec. 24, eff. September 1, 2011.
2023 Texas Statutes › Labor Code › Title 5 - Workers' Compensation › Subtitle A - Texas Workers' Compensation Act › Chapter 413 - Medical Review › Subchapter E. Implementation of Commission Powers and Duties › Section 413.05121. Quality Assurance Panel

Sec. 413.05121.  QUALITY ASSURANCE PANEL.  (a)  The medical advisor shall establish the quality assurance panel within the medical quality review panel to:
(1)  provide an additional level of evaluation in medical case reviews; and
(2)  assist the medical advisor in performing the advisor's duties under Section 413.0511(b)(6) and the medical quality review panel in performing that panel's duties under Section 413.0512.
(b)  Members of the quality assurance panel shall evaluate medical care and recommend enforcement actions to the medical advisor.
(c)  The quality assurance panel shall meet periodically to discuss issues and otherwise offer assistance to the medical advisor and the medical quality review panel under Subsection (a)(2).
Added by Acts 2011, 82nd Leg., R.S., Ch. 1162 (H.B. 2605), Sec. 24, eff. September 1, 2011.
2023 Texas Statutes › Labor Code › Title 5 - Workers' Compensation › Subtitle A - Texas Workers' Compensation Act › Chapter 413 - Medical Review › Subchapter E. Implementation of Commission Powers and Duties › Section 413.05122. Medical Quality Review Panel: Rules; Training

Sec. 413.05122.  MEDICAL QUALITY REVIEW PANEL: RULES; TRAINING.  (a)  The commissioner, after consultation with the medical advisor, shall adopt rules concerning the operation of the medical quality review panel, including rules that establish:
(1)  the qualifications necessary for a health care provider to serve on the medical quality review panel;
(2)  the composition of the medical quality review panel, including the number of members to be included on the panel and the health care specialty fields required to be represented by the members of the panel;
(3)  the maximum length of time a health care provider may serve on the medical quality review panel;
(4)  a policy defining situations that constitute a conflict of interest for a member of the medical quality review panel;
(5)  procedures and grounds for removing a member of the medical quality review panel from the panel, including as a ground for removal that a member is repeatedly delinquent in conducting case reviews; and
(6)  a procedure through which members of the medical quality review panel are notified concerning the status and enforcement outcomes of cases resulting from the medical quality review process.
(b)  In addition to the rules required under Subsection (a), the commissioner shall adopt rules concerning the training requirements for members of the medical quality review panel.  The rules adopted under this subsection must ensure that panel members are fully aware of any requirements imposed by this subtitle concerning the medical quality review process and the division's goals concerning the process.  The rules adopted under this subsection may require members to receive training on any topic determined by the division or the commissioner to be relevant to the operations of the panel and must require members of the panel to receive training concerning:
(1)  administrative violations that affect the delivery of appropriate medical care;
(2)  the confidentiality requirements described by Section 413.0513 and the immunity from liability provided to members of the panel under Section 413.054; and
(3)  the medical quality review criteria adopted under Section 413.05115.
Added by Acts 2011, 82nd Leg., R.S., Ch. 1162 (H.B. 2605), Sec. 24, eff. September 1, 2011.
2023 Texas Statutes › Labor Code › Title 5 - Workers' Compensation › Subtitle A - Texas Workers' Compensation Act › Chapter 413 - Medical Review › Subchapter E. Implementation of Commission Powers and Duties › Section 413.0513. Confidentiality Requirements

Sec. 413.0513.  CONFIDENTIALITY REQUIREMENTS.  (a)  Information collected, assembled, or maintained by or on behalf of the division under Section 413.0511 or 413.0512 constitutes an investigation file for purposes of Section 402.092 and may not be disclosed under Section 413.0511 or 413.0512 except as provided by that section.
(b)  Confidential information, and other information to which access is restricted by law, developed by or on behalf of the division under Section 413.0511 or 413.0512 is not subject to discovery or court subpoena in any action other than:
(1)  an action to enforce this subtitle brought by the division, an appropriate licensing or regulatory agency, or an appropriate enforcement authority; or
(2)  a criminal proceeding.
Added by Acts 2001, 77th Leg., ch. 1456, Sec. 1.02, eff. June 17, 2001.  Amended by Acts 2003, 78th Leg., ch. 963, Sec. 3, eff. June 20, 2003.
Amended by:
Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 3.253, eff. September 1, 2005.
2023 Texas Statutes › Labor Code › Title 5 - Workers' Compensation › Subtitle A - Texas Workers' Compensation Act › Chapter 413 - Medical Review › Subchapter E. Implementation of Commission Powers and Duties › Section 413.0515. Reports of Chiropractor Violations

Sec. 413.0515.  REPORTS OF CHIROPRACTOR VIOLATIONS.  (a)  Repealed by Acts 2021, 87th Leg., R.S., Ch. 856 (S.B. 800), Sec. 25(14), eff. September 1, 2021.
(b)  If the division or the Texas Board of Chiropractic Examiners discovers an act or omission by a chiropractor that may constitute a felony, a misdemeanor involving moral turpitude, a violation of state or federal narcotics or controlled substance law, an offense involving fraud or abuse under the Medicare or Medicaid program, or a violation of this subtitle, the discovering agency shall report in a widely used electronic format that act or omission to the other agency.
Added by Acts 2003, 78th Leg., ch. 963, Sec. 4, eff. June 20, 2003.
Amended by:
Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 3.255, eff. September 1, 2005.
Acts 2019, 86th Leg., R.S., Ch. 573 (S.B. 241), Sec. 1.41, eff. September 1, 2019.
Acts 2021, 87th Leg., R.S., Ch. 856 (S.B. 800), Sec. 22, eff. September 1, 2021.
Acts 2021, 87th Leg., R.S., Ch. 856 (S.B. 800), Sec. 25(14), eff. September 1, 2021.
2023 Texas Statutes › Labor Code › Title 5 - Workers' Compensation › Subtitle A - Texas Workers' Compensation Act › Chapter 413 - Medical Review › Subchapter E. Implementation of Commission Powers and Duties › Section 413.052. Production of Documents

Sec. 413.052.  PRODUCTION OF DOCUMENTS.  The commissioner by rule shall establish procedures to enable the division to compel the production of documents.
Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993.
Amended by:
Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 3.256, eff. September 1, 2005.
2023 Texas Statutes › Labor Code › Title 5 - Workers' Compensation › Subtitle A - Texas Workers' Compensation Act › Chapter 413 - Medical Review › Subchapter E. Implementation of Commission Powers and Duties › Section 413.053. Standards of Reporting and Billing

Sec. 413.053.  STANDARDS OF REPORTING AND BILLING.  The commissioner by rule shall establish standards of reporting and billing governing both form and content.
Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993.
Amended by:
Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 3.257, eff. September 1, 2005.
2023 Texas Statutes › Labor Code › Title 5 - Workers' Compensation › Subtitle A - Texas Workers' Compensation Act › Chapter 413 - Medical Review › Subchapter E. Implementation of Commission Powers and Duties › Section 413.054. Immunity From Liability

Sec. 413.054.  IMMUNITY FROM LIABILITY.  (a)  A person who performs services for the division as a designated doctor, an independent medical examiner, a doctor performing a medical case review, or a member of a peer review panel has the same immunity from liability as the commissioner under Section 402.00123.
(b)  Immunity from liability under this section does not apply to a person providing medical treatment to an injured employee.
Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993.
Amended by:
Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 3.258, eff. September 1, 2005.
Acts 2011, 82nd Leg., R.S., Ch. 1162 (H.B. 2605), Sec. 25, eff. September 1, 2011.
2023 Texas Statutes › Labor Code › Title 5 - Workers' Compensation › Subtitle A - Texas Workers' Compensation Act › Chapter 413 - Medical Review › Subchapter E. Implementation of Commission Powers and Duties › Section 413.055. Interlocutory Orders; Reimbursement

Sec. 413.055.  INTERLOCUTORY ORDERS;  REIMBURSEMENT.  (a)  The commissioner may enter an interlocutory order for the payment of all or part of medical benefits.  The order may address accrued benefits, future benefits, or both accrued benefits and future benefits.
(b)  The subsequent injury fund shall reimburse an insurance carrier for any overpayments of benefits made under an order entered under Subsection (a) if the order is reversed or modified by final arbitration, order, or decision of the commissioner or a court.  The commissioner shall adopt rules to provide for a periodic reimbursement schedule, providing for reimbursement at least annually.
(c)  A party that disputes an order entered under Subsection (a) is entitled to a hearing.  The hearing shall be conducted by the State Office of Administrative Hearings in the manner provided for a contested case under Chapter 2001, Government Code.  The order is binding during the pendency of the appeal.
Added by Acts 1999, 76th Leg., ch. 955, Sec. 6, eff. Sept. 1, 1999.
Amended by:
Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 3.259, eff. September 1, 2005.
2023 Texas Statutes › Labor Code › Title 5 - Workers' Compensation › Subtitle A - Texas Workers' Compensation Act › Chapter 414 - Enforcement of Compliance and Practice Requirements › Section 414.002. Monitoring Duties

Sec. 414.002.  MONITORING DUTIES.  (a)  The division shall monitor for compliance with commissioner rules, this subtitle, and other laws relating to workers' compensation the conduct of persons subject to this subtitle.  Persons to be monitored include:
(1)  persons claiming benefits under this subtitle;
(2)  employers;
(3)  insurance carriers;
(4)  attorneys and other representatives of parties; and
(5)  health care providers.
(b)  The division shall monitor conduct described by Sections 415.001, 415.002, and 415.003 and refer persons engaging in that conduct to the division of hearings.
(c)  The division shall monitor payments made to health care providers on behalf of workers' compensation claimants who receive medical services to ensure that the payments are made on time as required by Section 408.027.
Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993.
Amended by:
Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 3.260, eff. September 1, 2005.
2023 Texas Statutes › Labor Code › Title 5 - Workers' Compensation › Subtitle A - Texas Workers' Compensation Act › Chapter 414 - Enforcement of Compliance and Practice Requirements › Section 414.003. Compilation and Use of Information

Sec. 414.003.  COMPILATION AND USE OF INFORMATION.  (a)  The division shall compile and maintain statistical and other information as necessary to detect practices or patterns of conduct by persons subject to monitoring under this chapter that:
(1)  violate this subtitle, commissioner rules, or a commissioner order or decision; or
(2)  otherwise adversely affect the workers' compensation system of this state.
(b)  The commissioner shall use the information compiled under this section to impose appropriate penalties and other sanctions under Chapters 415 and 416.
Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993.
Amended by:
Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 3.261, eff. September 1, 2005.
2023 Texas Statutes › Labor Code › Title 5 - Workers' Compensation › Subtitle A - Texas Workers' Compensation Act › Chapter 414 - Enforcement of Compliance and Practice Requirements › Section 414.004. Performance Review of Insurance Carriers

Sec. 414.004.  PERFORMANCE REVIEW OF INSURANCE CARRIERS.  (a)  The division shall review regularly the workers' compensation records of insurance carriers as required to ensure compliance with this subtitle.
(b)  Each insurance carrier, the carrier's agents, and those with whom the carrier has contracted to provide, review, or monitor services under this subtitle shall:
(1)  cooperate with the division;
(2)  make available to the division any records or other necessary information;  and
(3)  allow the division access to the information at reasonable times at the person's offices.
(c)  The insurance carrier, other than a governmental entity, shall pay the reasonable expenses, including travel expenses, of an auditor who audits the workers' compensation records at the office of the insurance carrier.
Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993.
2023 Texas Statutes › Labor Code › Title 5 - Workers' Compensation › Subtitle A - Texas Workers' Compensation Act › Chapter 414 - Enforcement of Compliance and Practice Requirements › Section 414.005. Investigation Unit

Sec. 414.005.  INVESTIGATION UNIT.  (a)  The division shall maintain an investigation unit to conduct investigations relating to:
(1)  alleged violations of this subtitle, commissioner rules, or a commissioner order or decision, with particular emphasis on violations of Chapters 415 and 416; and
(2)  alleged offenses under this subtitle, with particular emphasis on offenses under Chapter 418.
(b)  As often as the commissioner considers necessary, the commissioner or the investigation unit may review the operations of a person regulated by the division, including an agent of the person performing functions regulated by the division, to determine compliance with this subtitle.
(c)  The review described by Subsection (b) may include on-site visits to the person's premises.  The commissioner is not required to announce an on-site visit in advance.
(d)  During an on-site visit, a person regulated by the division shall make available to the division all records relating to the person's participation in the workers' compensation system.
(e)  The commissioner by rule shall prescribe the procedures to be used for both announced and unannounced on-site visits authorized under this section, including specifying the types of records subject to inspection.
Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993.
Amended by:
Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 3.262, eff. September 1, 2005.
Acts 2011, 82nd Leg., R.S., Ch. 1162 (H.B. 2605), Sec. 26, eff. September 1, 2011.
Acts 2017, 85th Leg., R.S., Ch. 463 (H.B. 2053), Sec. 1, eff. June 9, 2017.
2023 Texas Statutes › Labor Code › Title 5 - Workers' Compensation › Subtitle A - Texas Workers' Compensation Act › Chapter 414 - Enforcement of Compliance and Practice Requirements › Section 414.006. Referral to Other Authorities

Sec. 414.006.  REFERRAL TO OTHER AUTHORITIES.  (a)  For further investigation or the institution of appropriate proceedings, the division may refer the persons involved in a case subject to an investigation to  other appropriate authorities, including licensing agencies, district and county attorneys, or the attorney general.
(b)  The division may provide technical or litigation assistance regarding the investigation referred under Subsection (a) to the appropriate authority.
Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993.
Amended by:
Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 3.263, eff. September 1, 2005.
Acts 2017, 85th Leg., R.S., Ch. 463 (H.B. 2053), Sec. 2, eff. June 9, 2017.
2023 Texas Statutes › Labor Code › Title 5 - Workers' Compensation › Subtitle A - Texas Workers' Compensation Act › Chapter 414 - Enforcement of Compliance and Practice Requirements › Section 414.007. Medical Review

Sec. 414.007.  MEDICAL REVIEW.  The division shall review information concerning alleged violations of this subtitle regarding the provision of medical benefits, commissioner rules, or a commissioner order or decision, and, under Sections 414.005 and 414.006 and Chapters 415 and 416, may conduct investigations, make referrals to other authorities, and initiate administrative violation proceedings.
Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993.
Amended by:
Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 3.264, eff. September 1, 2005.
2023 Texas Statutes › Labor Code › Title 5 - Workers' Compensation › Subtitle A - Texas Workers' Compensation Act › Chapter 415 - Administrative Violations › Subchapter A. Prohibited Acts › Section 415.001. Administrative Violation by Representative of Employee or Legal Beneficiary

Sec. 415.001.  ADMINISTRATIVE VIOLATION BY REPRESENTATIVE OF EMPLOYEE OR LEGAL BENEFICIARY.  A representative of an employee or legal beneficiary commits an administrative violation if the person:
(1)  fails without good cause to attend a dispute resolution proceeding within the division;
(2)  attends a dispute resolution proceeding within the division without complete authority or fails to exercise authority to effectuate an agreement or settlement;
(3)  commits an act of barratry under Section 38.12, Penal Code;
(4)  withholds from the employee's or legal beneficiary's weekly benefits or from advances amounts not authorized to be withheld by the division;
(5)  enters into a settlement or agreement without the knowledge, consent, and signature of the employee or legal beneficiary;
(6)  takes a fee or withholds expenses in excess of the amounts authorized by the division;
(7)  refuses or fails to make prompt delivery to the employee or legal beneficiary of funds belonging to the employee or legal beneficiary as a result of a settlement, agreement, order, or award;
(8)  violates the Texas Disciplinary Rules of Professional Conduct of the State Bar of Texas;
(9)  misrepresents the provisions of this subtitle to an employee, an employer, a health care provider, or a legal beneficiary;
(10)   violates a commissioner rule; or
(11)  fails to comply with this subtitle.
Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993.
Amended by:
Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 3.265, eff. September 1, 2005.
2023 Texas Statutes › Labor Code › Title 5 - Workers' Compensation › Subtitle A - Texas Workers' Compensation Act › Chapter 415 - Administrative Violations › Subchapter A. Prohibited Acts › Section 415.003. Administrative Violation by Health Care Provider

Sec. 415.003.  ADMINISTRATIVE VIOLATION BY HEALTH CARE PROVIDER.  A health care provider commits an administrative violation if the person:
(1)  submits a charge for health care that was not furnished;
(2)  administers improper, unreasonable, or medically unnecessary treatment or services;
(3)  makes an unnecessary referral;
(4)  violates the division's fee and treatment guidelines;
(5)  violates a commissioner rule; or
(6)  fails to comply with a provision of this subtitle.
Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993.  Amended by Acts 1995, 74th Leg., ch. 980, Sec. 1.45, eff. Sept. 1, 1995.
Amended by:
Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 3.267, eff. September 1, 2005.