reglab/statecodes huggingface dataset:
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 132 - DEATH BENEFITS-DEATH AND BURIAL BENEFITS › Section 132.9 - Duration of Death Benefits for an Eligible Grandchild, Eligible Dependent, and Eligible Parent

Current through Reg. 49, No. 28; July 12, 2024
(a) A grandchild,
				who is eligible to receive death benefits and is a minor at the time of the
				employee's death, is entitled to receive benefits until the earlier of:
(1) the date on which the grandchild turns
				18; or
(2) the date of death of the
				grandchild.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 132 - DEATH BENEFITS-DEATH AND BURIAL BENEFITS › Section 132.10 - Payment of Death Benefits to the Subsequent Injury Fund

Current through Reg. 49, No. 28; July 12, 2024
(a) If a compensable death occurs and the
				carrier's investigation, as described in §
									132.17
				of this title (relating to Denial, Dispute, and Payment of Death Benefits), has
				confirmed that the deceased employee has no legal beneficiaries, or if a claim
				for death benefits is not made in a timely manner, the insurance carrier shall,
				without order from the Commission, pay to the administrator of the Subsequent
				Injury Fund (SIF) an amount equal to 364 weeks of death benefits for deposit in
				the SIF. This payment shall be accompanied by the Employer's First Report of
				Injury and the Wage Statement.
(b)
				If, after a carrier has paid death benefits to all legal beneficiaries, all
				legal beneficiaries cease to be eligible to receive death benefits prior to the
				carrier paying a full 364 weeks of benefits, the carrier shall, without order
				from the Commission, pay the remainder of the 364 weeks of death benefits to
				the administrator of the SIF. The remainder to be paid to the SIF shall be
				computed by subtracting the total amount paid, including any applicable
				remarriage payment, from the 364 weeks of death benefits that the carrier is
				required to pay. This payment shall be accompanied by the Employer's First
				Report of Injury, the Wage Statement, a detailed payment record showing the
				dates of payments, the amounts of the payments, the payees, the periods of
				benefits paid, and any other documentation reasonably required by the SIF
				administrator.
(c) The payments
				required by subsections (a) and (b) shall be made no later than the seventh day
				after the latest of:
(1) the day that there
				has been final adjudication that a death is compensable and/or that the carrier
				is liable for death benefits (if a denial of compensability or liability had
				been filed in accordance with §
										132.17
				and §
										124.2
				of this title (relating to Carrier Reporting and Notification Requirements and
				Denials));
(2) the sixtieth day
				after the carrier received written notice of the injury;
(3) one year after the date of the employee's
				death, if no claims of beneficiary entitlement have been made;
(4) the day that beneficiary entitlement
				disputes are finally adjudicated with the beneficiary being found to not be
				entitled to death benefits; or
(5)
				the day that all previously eligible beneficiaries are no longer eligible to
				receive death benefits.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 132 - DEATH BENEFITS-DEATH AND BURIAL BENEFITS › Section 132.11 - Distribution of Death Benefits

Current through Reg. 49, No. 28; July 12, 2024
(a) All of the
				death benefits shall be paid to the eligible spouse if the deceased employee
				had no eligible children or eligible grandchildren.
(b) Death benefits shall be paid in equal
				shares to each eligible child per capita and to each eligible grandchild per
				stirpes if there is no eligible spouse.
(c) If there is an eligible spouse and an
				eligible child or eligible grandchild, half of the death benefits shall be paid
				to the eligible spouse. The remaining half shall be paid:
(1) if there are no eligible grandchildren,
				in equal shares to the eligible children;
(2) if there are no eligible children, per
				stirpes to the eligible grandchildren; or
(3) if there are eligible children and
				eligible grandchildren, the eligible children shall be paid equal shares per
				capita and the eligible grandchildren shall be paid per stirpes.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 132 - DEATH BENEFITS-DEATH AND BURIAL BENEFITS › Section 132.12 - Redistribution of Death Benefits

Current through Reg. 49, No. 28; July 12, 2024
(a) Death
				benefits shall be redistributed if a legal beneficiary dies or becomes
				ineligible to receive benefits. The benefits shall be redistributed to the
				remaining legal beneficiaries eligible to receive death benefits at the time of
				death of the employee.
(b) If an
				eligible spouse becomes disqualified from continued payment of death benefits
				because of remarriage, the amount of benefits paid to each remaining legal
				beneficiary shall remain the same for 104 weeks. At the expiration of 104
				weeks, the amount of benefits paid to each remaining legal beneficiary shall be
				recalculated as provided in §
									132.11
				of this title (relating to Distribution of Death Benefits).
(c) If 364 weeks of death benefit payments
				have not been paid and the only remaining legal beneficiary is the subsequent
				injury fund, the insurance carrier shall pay any remaining amounts to the
				subsequent injury fund in accordance with §
									132.10
				of this title (relating to Payment of Death Benefits to the Subsequent Injury
				Fund).
(d) In no case shall the
				insurance carrier pay an amount less than the weekly death benefit multiplied
				by 364, taking into consideration the discount rate set out in the Texas
				Workers' Compensation Act, §1.04, for a commuted payment to the subsequent
				injury fund in subsection (c) of this section.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 132 - DEATH BENEFITS-DEATH AND BURIAL BENEFITS › Section 132.13 - Burial Benefits

Current through Reg. 49, No. 28; July 12, 2024
(a) When an
				employee has died as the result of a compensable injury, a person claiming
				burial benefits shall file a request for payment of burial benefits and the
				bills showing the amount of burial and transportation costs incurred. The
				request and the documentation shall be filed with the insurance carrier within
				12 months of the date of death of the employee.
(b) The person who incurred liability for the
				costs of burial is entitled to receive the lesser of:
(1) the actual costs incurred for reasonable
				burial expenses; or
(2) $2,500--if
				burial benefits are paid based on a compensable injury that occurs before
				September 1, 1999; or
(3)
				$6,000--if burial benefits are paid based on a compensable injury that occurs
				on or after September 1, 1999 and before September 1, 2015; or
(4) $10,000--if burial benefits are paid
				based on a compensable injury that occurs on or after September 1,
				2015.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 132 - DEATH BENEFITS-DEATH AND BURIAL BENEFITS › Section 132.14 - Autopsy

Current through Reg. 49, No. 28; July 12, 2024
(a) In a claim for death benefits based on an
				occupational disease, an autopsy may be requested by:
(1) an insurance carrier or the commission;
				or
(2) any legal beneficiary if the
				claim for benefits is denied.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 132 - DEATH BENEFITS-DEATH AND BURIAL BENEFITS › Section 132.15 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms, when used in this chapter,
				  shall have the following meanings, unless the context clearly indicates
				  otherwise.
(1) Accredited educational
				institution--An institution which provides a recognized course or courses of
				instruction and leads to the conference of a diploma, degree, or other
				recognized certification of completion at the conclusion of the course of
				study. The definition may include, but is not limited to, high schools,
				colleges and universities, and trade schools.
(2) Full-time student--A person enrolled in
				at least the minimum course load required to qualify as full-time at the
				particular educational institution and in the particular course of
				study.
(3) Semester--The periods by
				which the educational institution divides its academic year.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 132 - DEATH BENEFITS-DEATH AND BURIAL BENEFITS › Section 132.16 - Change in Payment Periods; Purchase of Annuity for Death Benefits

Current through Reg. 49, No. 28; July 12, 2024
(a) Upon the request of the eligible
				beneficiaries, the insurance carrier and eligible beneficiaries entitled to
				death benefits may agree to change the frequency of death benefits payments
				from the standard weekly period to a monthly period. The agreement to change
				the payment frequency must be in writing. To relieve the insurance carrier of
				the responsibility to pay death benefits weekly:
(1) An application to change the frequency of
				payments must be submitted to the Commission with the written agreement for
				approval in the form, format and manner required by the Commission
(2) A separate application must be submitted
				to the Commission for each eligible beneficiary, and the application must state
				that a payment adjustment shall be made when there is a change in the
				individual beneficiary's eligibility status in accordance with the provisions
				of the Act.
(3) If less than the
				maximum weekly death benefit in effect at the time of death is being paid, a
				completed Employer's Wage Statement (Form TWCC-3) must be filed with the
				application to change the payment period.
(4) The written agreement for monthly payment
				of death benefits must include:
(A) the
				agreement for the monthly payment of death benefits will be effective the first
				calendar day of the month following the month in which the written agreement
				was approved by the Commission;
(B)
				payment of monthly death benefits shall be issued on or before the seventh day
				of the month for which benefits are due.
(C) continuation of weekly death benefits
				payments through the end of the month in which the agreement was
				approved;
(D) payment of the last
				week of death benefits to transition from weekly payment of death benefits to
				monthly payments shall be prorated to the end of the month to ensure the
				eligible beneficiaries receives death benefits through the last day of the
				month; and
(E) calculation of the
				monthly compensation rate by multiplying the weekly compensation rate by
				4.34821.
(5) The
				Commission must approve the application to change the frequency of death
				benefit payments.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 133 - GENERAL MEDICAL PROVISIONS › Subchapter A - GENERAL RULES FOR MEDICAL BILLING AND PROCESSING › Section 133.1 - Applicability of Medical Billing and Processing

Current through Reg. 49, No. 28; July 12, 2024
(a) This chapter applies to medical billing
				  and processing for health care services provided to injured employees subject
				  to a workers' compensation health care network established under Insurance Code
				  Chapter 1305, and to injured employees not subject to such networks, with the
				  following exceptions pertaining only to health care services provided to an
				  injured employee subject to a workers' compensation health care network
				  established under Chapter 1305:
(1)
				  Subchapter D of this chapter (relating to Dispute of Medical Bills);
(2)
											§
											133.210(f)
				  of this chapter (relating to Medical Documentation); and
(3)
											§
											133.240(b)
				  and (i) of this chapter (relating to Medical
				  Payments and Denials).
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 133 - GENERAL MEDICAL PROVISIONS › Subchapter A - GENERAL RULES FOR MEDICAL BILLING AND PROCESSING › Section 133.2 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms, when used in this chapter,
					 shall have the following meanings, unless the context clearly indicates
					 otherwise:
(1) Adverse
				  determination--A determination by a utilization review agent made on behalf of
				  a payor that the health care services provided or proposed to be provided to an
				  injured employee are not medically necessary or appropriate. The term does not
				  include a denial of health care services due to the failure to request
				  prospective or concurrent utilization review. An adverse determination does not
				  include a determination that health care services are experimental or
				  investigational.
(2) Agent--A
				  person whom a system participant utilizes or contracts with for the purpose of
				  providing claims service or fulfilling medical bill processing obligations
				  under Labor Code, Title 5 and rules. The system participant who utilizes or
				  contracts with the agent may also be responsible for the administrative
				  violations of that agent. This definition does not apply to "agent" as used in
				  the term "pharmacy processing agent."
(3) Bill review--Review of any aspect of a
				  medical bill, including retrospective review, in accordance with the Labor
				  Code, the Insurance Code, division or department rules, and the appropriate fee
				  and treatment guidelines.
(4)
				  Complete medical bill--A medical bill that contains all required fields as set
				  forth in the billing instructions for the appropriate form specified in §
										133.10
				  of this chapter (relating to Required Billing Forms/Formats), or as specified
				  for electronic medical bills in §
										133.500
				  of this chapter (relating to Electronic Formats for Electronic Medical Bill
				  Processing).
(5) Emergency--Either
				  a medical or mental health emergency as follows:
(A) a medical emergency is the sudden onset
				  of a medical condition manifested by acute symptoms of sufficient severity,
				  including severe pain, that the absence of immediate medical attention could
				  reasonably be expected to result in:
(i)
				  placing the patient's health or bodily functions in serious jeopardy,
				  or
(ii) serious dysfunction of any
				  body organ or part;
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 133 - GENERAL MEDICAL PROVISIONS › Subchapter A - GENERAL RULES FOR MEDICAL BILLING AND PROCESSING › Section 133.3 - Communication Between Health Care Providers and Insurance Carriers

Current through Reg. 49, No. 28; July 12, 2024
(a) Any communication between the health care
				  provider and insurance carrier related to medical bill processing shall be of
				  sufficient, specific detail to allow the responder to easily identify the
				  information required to resolve the issue or question related to the medical
				  bill. Generic statements that simply state a conclusion such as "insurance
				  carrier improperly reduced the bill" or "health care provider did not document"
				  or other similar phrases with no further description of the factual basis for
				  the sender's position does not satisfy the requirements of this
				  section.
(b) Communication between
				  the health care provider and insurance carrier related to medical bill
				  processing shall be made by telephone or electronic transmission unless the
				  information cannot be sent by those media, in which case the sender shall send
				  the information by mail or personal delivery.
(c) Health care providers and insurance
				  carriers shall maintain, in a reproducible format, documentation of
				  communications related to medical bill processing.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 133 - GENERAL MEDICAL PROVISIONS › Subchapter A - GENERAL RULES FOR MEDICAL BILLING AND PROCESSING › Section 133.4 - Written Notification to Health Care Providers of Contractual Agreements for Informal and Voluntary Networks

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  Applicability. This section applies to health care services that are rendered
				  between August 1, 2008, and December 31, 2010, pursuant to an informal network
				  or voluntary network fee agreement with a health care provider in accordance
				  with Labor Code §
										413.011
				  and §
										413.0115.
(b) Person. Under this section "person" is
				  defined as an individual, partnership, corporation, hospital district,
				  insurance carrier, organization, business trust, estate trust, association,
				  limited liability company, limited liability partnership or other entity to
				  whom an informal network or voluntary network's fee arrangement with a health
				  care provider is sold, leased, transferred, or conveyed on behalf of an
				  insurance carrier. This term does not include an injured employee.
(c) Required Notice. Each informal network or
				  voluntary network, or the insurance carrier, or the insurance carrier's
				  authorized agent, as appropriate, shall notify each affected health care
				  provider of any person that is given access to the informal or voluntary
				  network's fee arrangement with that health care provider within the time and
				  manner provided by this section.
(d) Notice. Notice to each contracted health
				  care provider:
(1) must include the contact
				  information for the informal or voluntary network, including, but not limited
				  to, the name, physical address, and a toll-free telephone number accessible to
				  all contracted health care providers;
(2) must include the following information in
				  the body of the notice:
(A) name, physical
				  address, and telephone number of any person that is given access to the
				  informal or voluntary network's fee arrangement with a health care provider;
				  and
(B) the start date and any end
				  date during which any person has been given access to the health care
				  provider's contracted fee arrangement.
(3) may be provided in an electronic format
				  provided a paper version is available upon request by the Texas Department of
				  Insurance, Division of Workers' Compensation (Division); and
(4) may be provided through a website link
				  only if the website:
(A) contains the
				  information stated in paragraphs (1), (2)(A) and (2)(B) of this subsection;
				  and
(B) is updated at least monthly
				  with current and correct information.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 133 - GENERAL MEDICAL PROVISIONS › Subchapter A - GENERAL RULES FOR MEDICAL BILLING AND PROCESSING › Section 133.5 - Informal Network and Voluntary Network Reporting Requirements to the Division

Current through Reg. 49, No. 28; July 12, 2024
(a) Reporting Requirement. Each informal
				  network and voluntary network must provide the following information to the
				  Texas Department of Insurance, Division of Workers' Compensation (Division):
(1) the informal network or voluntary
				  network's name and federal employer identification number (FEIN);
(2) an executive contact for official
				  correspondence for the informal network or voluntary network;
(3) a toll-free telephone number by which a
				  health care provider may contact the informal network or voluntary
				  network;
(4) a list of each
				  insurance carrier with whom the informal network or voluntary network
				  contracts, including the insurance carrier's FEIN; and
(5) a list of each entity or insurance
				  carrier agent associated with the informal or voluntary network working on
				  behalf of the insurance carrier, including contact information for each
				  entity.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 133 - GENERAL MEDICAL PROVISIONS › Subchapter B - HEALTH CARE PROVIDER BILLING PROCEDURES › Section 133.10 - Required Billing Forms/Formats

Current through Reg. 49, No. 28; July 12, 2024
(a) Health care
				  providers, including those providing services for a certified workers'
				  compensation health care network as defined in Insurance Code Chapter 1305 or
				  to political subdivisions with contractual relationships under Labor Code
				  §
										504.053(b)(2),
				  must submit medical bills for payment in an electronic format in accordance
				  with §
										133.500 and §
										133.501 of this title (relating to
				  Electronic Formats for Electronic Medical Bill Processing and Electronic
				  Medical Bill Processing), unless the health care provider or the billed
				  insurance carrier is exempt from the electronic billing process in accordance
				  with §
										133.501 of this title.
(b) Except as provided in subsection (a) of
				  this section, health care providers, including those providing services for a
				  certified workers' compensation health care network as defined in Insurance
				  Code Chapter 1305 or to political subdivisions with contractual relationships
				  under Labor Code §
										504.053(b)(2),
				  must submit paper medical bills for payment on:
(1) the 1500 Health Insurance Claim Form
				  Version 02/12 (CMS-1500);
(2) the
				  Uniform Bill 04 (UB-04); or
(3)
				  applicable forms prescribed for pharmacists, dentists, and surgical implant
				  providers specified in subsections (c), (d), and (e) of this section.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 133 - GENERAL MEDICAL PROVISIONS › Subchapter B - HEALTH CARE PROVIDER BILLING PROCEDURES › Section 133.20 - Medical Bill Submission by Health Care Provider

Current through Reg. 49, No. 28; July 12, 2024
(a) The health care
				  provider must submit all medical bills to the insurance carrier except when
				  billing the employer in accordance with subsection (j) of this
				  section.
(b) Except as provided in
				  Labor Code §
										408.0272(b),
				  (c), or (d), a health care provider must not
				  submit a medical bill later than the 95th day after the date the services are
				  provided.
(1) If a designated doctor refers an
				  injured employee for additional testing or evaluation under §
											127.10 of this title, the 95-day
				  period for timely submission of the bill begins on the date of service of the
				  additional testing or evaluation.
(2) In accordance with subsection (c) of the
				  statute, the health care provider must submit the medical bill to the correct
				  workers' compensation insurance carrier no later than the 95th day after the
				  date the health care provider is notified of the health care provider's
				  erroneous submission of the medical bill.
(3) A health care provider who submits a
				  medical bill to the correct workers' compensation insurance carrier must
				  include a copy of the original medical bill submitted, a copy of the
				  explanation of benefits (EOB) if available, and sufficient documentation to
				  support why one or more of the exceptions for untimely submission of a medical
				  bill under §408.0272 should be applied. The medical bill submitted by the
				  health care provider to the correct workers' compensation insurance carrier is
				  subject to the billing, review, and dispute processes established by Chapter
				  133, including §133.307(c)(2)(A) - (H) of this title (relating to MDR of
				  Fee Disputes), which establishes the generally acceptable standards for
				  documentation.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 133 - GENERAL MEDICAL PROVISIONS › Subchapter B - HEALTH CARE PROVIDER BILLING PROCEDURES › Section 133.30 - Telemedicine, Telehealth, and Teledentistry Services

Current through Reg. 49, No. 28; July 12, 2024
(a) This section applies to medical billing
				  and reimbursement for telemedicine, telehealth, and teledentistry services
				  provided on or after September 1, 2021, to injured employees in the Texas
				  workers' compensation system, including injured employees subject to a workers'
				  compensation health care network established under Insurance Code Chapter
				  1305.
(b) For the purposes of this
				  section:
(1) "telemedicine services" means
				  telemedicine medical services as defined in Occupations Code §
											111.001;
(2) "telehealth services" means telehealth
				  services as defined in Occupations Code §
											111.001;
				  and
(3) "teledentistry services"
				  means teledentistry dental services as defined in Occupations Code §
											111.001.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 133 - GENERAL MEDICAL PROVISIONS › Subchapter C - MEDICAL BILL PROCESSING/AUDIT BY INSURANCE CARRIER › Section 133.200 - Insurance Carrier Receipt of Medical Bills from Health Care Providers

Current through Reg. 49, No. 28; July 12, 2024
(a) On receipt of
				  medical bills submitted in accordance with §
										133.10 of this chapter (relating
				  to Required Billing Forms/Formats), an insurance carrier must evaluate each
				  medical bill for completeness as defined in §
										133.2 of this chapter (relating to
				  Definitions).
(1) Insurance carriers must not
				  return medical bills that are complete, unless the bill is a duplicate
				  bill.
(2) Within 30 days after the
				  day it receives a medical bill that is not complete as defined in §
											133.2 of this chapter, an
				  insurance carrier must:
(A) complete the bill
				  by adding missing information already known to the insurance carrier, except
				  for the following:
(i) dates of
				  service;
(ii) procedure or modifier
				  codes;
(iii) number of units;
				  and
(iv) charges; or
(B) return the bill to the sender,
				  in accordance with subsection (c) of this section.
(3) The insurance carrier may contact the
				  sender to get the information necessary to make the bill complete, including
				  the information specified in paragraph (2)(A)(i) - (iv) of this subsection. If
				  the insurance carrier gets the missing information and completes the bill, the
				  insurance carrier must document the name and telephone number of the person who
				  supplied the information.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 133 - GENERAL MEDICAL PROVISIONS › Subchapter C - MEDICAL BILL PROCESSING/AUDIT BY INSURANCE CARRIER › Section 133.210 - Medical Documentation

Current through Reg. 49, No. 28; July 12, 2024
(a) Medical
				  documentation includes all medical reports and records, such as evaluation
				  reports, narrative reports, assessment reports, progress report/notes, clinical
				  notes, hospital records and diagnostic test results.
(b) When submitting a medical bill for
				  reimbursement, the health care provider shall provide required documentation in
				  legible form, unless the required documentation was previously provided to the
				  insurance carrier or its agents.
(c) In addition to the documentation
				  requirements of subsection (b) of this section, medical bills for the following
				  services shall include the following supporting documentation:
(1) the two highest Evaluation and Management
				  office visit codes for new and established patients: office visit notes/report
				  satisfying the American Medical Association requirements for use of those CPT
				  codes;
(2) surgical services
				  rendered on the same date for which the total of the fees established in the
				  current Division fee guideline exceeds $500: a copy of the operative
				  report;
(3) return to work
				  rehabilitation programs as defined in §
											134.202
				  of this title (relating to Medical Fee Guideline): a copy of progress notes
				  and/or SOAP (subjective/objective assessment plan/procedure) notes, which
				  substantiate the care given, and indicate progress, improvement, the date of
				  the next treatment(s) and/or service(s), complications, and expected release
				  dates;
(4) any supporting
				  documentation for procedures which do not have an established Division maximum
				  allowable reimbursement (MAR), to include an exact description of the health
				  care provided; and
(5) for hospital
				  services: an itemized statement of charges.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 133 - GENERAL MEDICAL PROVISIONS › Subchapter C - MEDICAL BILL PROCESSING/AUDIT BY INSURANCE CARRIER › Section 133.230 - Insurance Carrier Audit of a Medical Bill

Current through Reg. 49, No. 28; July 12, 2024
(a) An insurance carrier may perform an audit
				  of a medical bill that has been submitted by a health care provider to the
				  insurance carrier for reimbursement. The insurance carrier may not audit a
				  medical bill upon which it has taken final action.
(b) If an insurance carrier decides to
				  conduct an audit of a medical bill, the insurance carrier shall:
(1) provide notice to the health care
				  provider no later than the 45th day after the date the insurance carrier
				  received the complete medical bill. For onsite audits, provide notice in
				  accordance with subsection (c) of this section;
(2) pay to the health care provider no later
				  than the 45th day after receipt of the health care provider's medical bill, for
				  the health care being audited:
(A) for a
				  workers' compensation health care network established under Insurance Code
				  Chapter 1305, 85 percent of the applicable contracted amount; or
(B) for services not provided under Insurance
				  Code Chapter 1305, 85 percent of:
(i) the
				  maximum allowable reimbursement amounts established under the applicable
				  Division fee guidelines;
(ii) the
				  contracted amount for services not addressed by Division fee guidelines;
				  or
(iii) the fair and reasonable
				  reimbursement in accordance with §
													134.1 of
				  this title (relating to Medical Reimbursement) for services not addressed by
				  clause (i) or (ii) of this subparagraph;
(3) make a determination regarding the
				  relationship of the health care services provided for the compensable injury,
				  the extent of the injury, and the medical necessity of the services provided;
				  and
(4) complete the audit and pay,
				  reduce, or deny in accordance with §
											133.240
				  of this chapter (relating to Medical Payments and Denials) no later than the
				  160th day after receipt of the complete medical bill.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 133 - GENERAL MEDICAL PROVISIONS › Subchapter C - MEDICAL BILL PROCESSING/AUDIT BY INSURANCE CARRIER › Section 133.250 - Reconsideration for Payment of Medical Bills

Current through Reg. 49, No. 28; July 12, 2024
(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.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 133 - GENERAL MEDICAL PROVISIONS › Subchapter C - MEDICAL BILL PROCESSING/AUDIT BY INSURANCE CARRIER › Section 133.260 - Refunds

Current through Reg. 49, No. 28; July 12, 2024
(a) An insurance carrier shall request a
				  refund within 240 days from the date of service or 30 days from completion of
				  an audit performed in accordance with §133.230 (relating to Insurance
				  Carrier Audit of a Medical Bill), whichever is later, when it determines that
				  inappropriate health care was previously reimbursed, or when an overpayment was
				  made for health care provided.
(b)
				  The insurance carrier shall submit the refund request to the health care
				  provider in an explanation of benefits in the form and manner prescribed by the
				  Division.
(c) A health care
				  provider shall respond to a request for a refund from an insurance carrier by
				  the 45th day after receipt of the request by:
(1) paying the requested amount; or
(2) submitting an appeal to the insurance
				  carrier with a specific explanation of the reason the health care provider has
				  failed to remit payment.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 133 - GENERAL MEDICAL PROVISIONS › Subchapter C - MEDICAL BILL PROCESSING/AUDIT BY INSURANCE CARRIER › Section 133.270 - Injured Employee Reimbursement for Health Care Paid

Current through Reg. 49, No. 28; July 12, 2024
(a) An injured employee may request
				  reimbursement from the insurance carrier when the injured employee has paid for
				  health care provided for a compensable injury, unless the injured employee is
				  liable for payment as specified in:
(1)
				  Insurance Code §
											1305.451,
				  or
(2) Section
				  134.504
				  of this title (relating to Pharmaceutical Expenses Incurred by the Injured
				  Employee).
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 133 - GENERAL MEDICAL PROVISIONS › Subchapter C - MEDICAL BILL PROCESSING/AUDIT BY INSURANCE CARRIER › Section 133.280 - Employer Reimbursement for Health Care Paid

Current through Reg. 49, No. 28; July 12, 2024
(a) An employer may request reimbursement
				  from the insurance carrier when the employer has paid for health care provided
				  for a compensable injury, and provided notice of injury in compliance with
				  Labor Code §
										409.005.
(b) The employer shall be reimbursed in
				  accordance with §134.1.
(c)
				  The employer may seek reimbursement for any payment made above the Division fee
				  guideline or contract amount from the health care provider who received the
				  overpayment.
(d) The employer's
				  request for reimbursement shall be legible and shall include:
(1) a copy of the health care provider's
				  required billing form;
(2) any
				  supporting documentation submitted by the health care provider as required in
				  §
											133.210 of
				  this chapter (relating to Medical Documentation); and
(3) documentation of the payment to the
				  health care provider.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 133 - GENERAL MEDICAL PROVISIONS › Subchapter D - DISPUTE OF MEDICAL BILLS › Section 133.306 - Interlocutory Orders for Medical Benefits

Current through Reg. 49, No. 28; July 12, 2024
(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.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 133 - GENERAL MEDICAL PROVISIONS › Subchapter D - DISPUTE OF MEDICAL BILLS › Section 133.307 - Medical Fee Dispute Resolution

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  Applicability. This section applies to a request to the division for medical
				  fee dispute resolution (MFDR) as authorized by the Texas Workers' Compensation
				  Act.
(1) Dispute resolution requests must be
				  resolved in accordance with the statutes and rules in effect at the time the
				  request was filed.
(2) In resolving
				  disputes regarding the amount of payment due for health care determined to be
				  medically necessary and appropriate for treatment of a compensable injury, the
				  role of the division is to adjudicate the payment, given the relevant statutory
				  provisions and division rules.
(3)
				  In accordance with Labor Code §
											504.055 a request for
				  medical fee dispute resolution that involves a first responder's request for
				  reimbursement of medical expenses paid by the first responder will be
				  accelerated by the division and given priority. The first responder shall
				  provide notice to the division that the request involves a first
				  responder.
(4) The 2020 amendments
				  regarding electronic submission of dispute requests are effective February 22,
				  2021.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 133 - GENERAL MEDICAL PROVISIONS › Subchapter D - DISPUTE OF MEDICAL BILLS › Section 133.308 - MDR of Medical Necessity Disputes

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  Applicability. The applicability of this section is as follows.
(1) This section applies to the independent
				  review of medical necessity disputes that are filed on or after June 1, 2012.
				  Dispute resolution requests filed prior to June 1, 2012 shall be resolved in
				  accordance with the statutes and rules in effect at the time the request was
				  filed.
(2) When applicable,
				  retrospective medical necessity disputes shall be governed by the provisions of
				  Labor Code §
											413.031(n)
				  and related rules.
(3) All
				  independent review organizations (IROs) performing reviews of health care under
				  the Labor Code and Insurance Code, regardless of where the independent review
				  activities are located, shall comply with this section. The Insurance Code, the
				  Labor Code and related rules govern the independent review process.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 133 - GENERAL MEDICAL PROVISIONS › Subchapter D - DISPUTE OF MEDICAL BILLS › Section 133.309 - Alternate Medical Necessity Dispute Resolution by Case Review Doctor

Current through Reg. 49, No. 28; July 12, 2024
(a) Definitions. The following terms, when
				  used in this section, shall have the following meanings, unless the context
				  clearly indicates otherwise:
(1) case review
				  doctor--a commission selected doctor from the commission's Approved Doctor List
				  assigned to conduct retrospective review of health care for medical necessity
				  under this subsection.
(2)
				  claim-specific--pertaining to one injured employee, a single workers'
				  compensation claim filed by that injured employee, and a single insurance
				  carrier (carrier), as defined in §
											133.1(a)(10)
				  of this title (relating to Definitions for Chapter 133, Benefits--Medical
				  Benefits), that has accepted liability for the claim.
(3) retrospective medical necessity
				  dispute--a dispute regarding health care provided to an injured employee by a
				  health care provider (HCP), as defined in §
											133.1(a)(9)
				  of this title, for which reimbursement has been denied to an injured employee
				  or HCP by the carrier based upon the carrier's determination that the health
				  care is not medically necessary.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 133 - GENERAL MEDICAL PROVISIONS › Subchapter G - ELECTRONIC MEDICAL BILLING, REIMBURSEMENT, AND DOCUMENTATION › Section 133.500 - Electronic Formats for Electronic Medical Bill Processing

Current through Reg. 49, No. 28; July 12, 2024
(a) For electronic transactions conducted
				  before January 1, 2012, the division adopts by reference the following
				  electronic medical bill processing standards as adopted by the United States
				  Department of Health and Human Services in
				  45
				  CFR §162.1102(b) and
				  §
										162.1602(b):
(1) Professional Billing--the ASC X12N 837,
				  Health Care Claim: Professional, Volumes 1 and 2, Version 004010, May 2000,
				  Washington Publishing Company, 004010X098 and Addenda to Health Care Claim:
				  Professional, Volumes 1 and 2, Version 4010, October 2002, Washington
				  Publishing Company, 004010X098A1.
(2) Institutional/Hospital Billing--the ASC
				  X12N 837, Health Care Claim: Institutional, Volumes 1 and 2, Version 004010,
				  May 2000, Washington Publishing Company, 004010X096 and Addenda to Health Care
				  Claim: Institutional, Volumes 1 and 2, Version 4010, October 2002, Washington
				  Publishing Company, 004010X096A1.
(3) Dental Billing--the ASC X12N 837, Health
				  Care Claim: Dental, Version 004010, May 2000, Washington Publishing Company,
				  004010X097 and Addenda to Health Care Claim: Dental, Version 4010, October
				  2002, Washington Publishing Company, 004010X097A1.
(4) Retail Pharmacy Billing--the
				  Telecommunication Standard Implementation Guide Version 5, Release 1 (Version
				  5.1), September 1999, National Council for Prescription Drug Programs and the
				  Batch Standard Batch Implementation Guide, Version 1, Release 1 (Version 1.1),
				  January 2000, supporting Telecommunication Standard Implementation Guide,
				  Version 5, Release 1 (Version 5.1) for the NCPDP Data Record in the Detail Data
				  Record, National Council for Prescription Drug Programs.
(5) Remittance--the ASC X12N 835, Health Care
				  Claim Payment/Advice, Version 004010, May 2000, Washington Publishing Company,
				  004010X091, and Addenda to Health Care Claim Payment/Advice, Version 4010,
				  October 2002, Washington Publishing Company, 004010X091A1.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 133 - GENERAL MEDICAL PROVISIONS › Subchapter G - ELECTRONIC MEDICAL BILLING, REIMBURSEMENT, AND DOCUMENTATION › Section 133.501 - Electronic Medical Bill Processing

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  Applicability.
(1) This section applies to
				  the exchange of electronic medical bill data in accordance with §
											133.500
				  of this title (relating to Electronic Formats for Electronic Medical Bill
				  Processing) for professional, institutional/hospital, pharmacy, and dental
				  services. This section applies to all electronic medical bill processing,
				  including transactions for medical services rendered under the provisions of
				  Insurance Code Chapter 1305 or rendered to political subdivisions with
				  contractual relationships under Labor Code §
											504.053(b)(2).
(2) Insurance carriers shall accept
				  electronic medical bills from health care providers transmitted in accordance
				  with §
											133.500
				  of this title unless the insurance carrier is exempt from the process in
				  accordance with subsection (b) of this section.
(3) Health care providers shall submit
				  electronic medical bills to insurance carriers in accordance with §
											133.500
				  of this title unless the health care provider or the billed insurance carrier
				  is exempt from the process in accordance with subsection (b) of this
				  section.