reglab/statecodes huggingface dataset:
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 133.502 - Electronic Medical Billing Supplemental Data Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a) In addition to
				  the data requirements and standards adopted under §
										133.500(a) of
				  this title (relating to Electronic Formats for Electronic Medical Bill
				  Processing), all professional, institutional or hospital, and dental electronic
				  medical bills submitted before January 1, 2012, must contain:
(1) the telephone number of the
				  submitter;
(2) the workers'
				  compensation claim number assigned by the insurance carrier or, if that number
				  is not known by the health care provider, a default value of
				  "UNKNOWN";
(3) the injured
				  employee's Social Security number as the subscriber member identification
				  number;
(4) the injured employee's
				  date of injury;
(5) the rendering
				  health care provider's state provider license number;
(6) the referring health care provider's
				  state provider license number;
(7)
				  the billing provider's state provider license number, if the billing provider
				  has a state provider license number;
(8) the attending physician's state medical
				  license number, when applicable;
(9) the operating physician's state medical
				  license number, when applicable;
(10) the claim supplemental information, when
				  electronic documentation is submitted with an electronic medical bill;
				  and
(11) the resubmission condition
				  code, when the electronic medical bill is a duplicate, request for
				  reconsideration, or other resubmission.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 134 - BENEFITS-GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS › Subchapter A - MEDICAL REIMBURSEMENT POLICIES › Section 134.1 - Medical Reimbursement

Current through Reg. 49, No. 28; July 12, 2024
(a) "Maximum
				  allowable reimbursement" (MAR), when used in this chapter, is defined as the
				  maximum amount payable to a health care provider in the absence of a
				  contractual fee arrangement that is consistent with §
										413.011
				  of the Labor Code, and Division rules.
(b) Medical reimbursement for health care
				  services provided to injured employees subject to a workers' compensation
				  health care network established under Insurance Code Chapter 1305 shall be made
				  in accordance with the provisions of Insurance Code Chapter 1305, except as
				  provided in subsections (c) and (d) of this section.
(c) Examinations conducted pursuant to Labor
				  Code §§
										408.004,
				  408.0041,
				  and
				  408.151
				  shall be reimbursed in accordance with §
										134.204
				  of this chapter (relating to Medical Fee Guideline for Workers' Compensation
				  Specific Services).
(d)
				  Examinations conducted pursuant to Labor Code §
										408.0042
				  shall be reimbursed in accordance with §
										126.14
				  of this title (relating to Treating Doctor Examination to Define the
				  Compensable Injury).
(e) Medical
				  reimbursement for health care not provided through a workers' compensation
				  health care network shall be made in accordance with:
(1) the Division's fee guidelines;
(2) a negotiated contract; or
(3) in the absence of an applicable fee
				  guideline or a negotiated contract, a fair and reasonable reimbursement amount
				  as specified in subsection (f) of this section.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 134 - BENEFITS-GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS › Subchapter A - MEDICAL REIMBURSEMENT POLICIES › Section 134.2 - Incentive Payments for Workers' Compensation Underserved Areas

Current through Reg. 49, No. 28; July 12, 2024
(a) When required by Division rule, an
				  incentive payment shall be added to the maximum allowable reimbursement (MAR)
				  for services performed in a designated workers' compensation underserved
				  area.
(b) The following list of ZIP
				  Codes comprise the Division designated workers' compensation underserved areas:
				  75134, 75135, 75161, 75181, 75212, 75410, 75558, 75603, 75630, 75650, 75653,
				  75654, 75658, 75660, 75663, 75666, 75667, 75672, 75687, 75692, 75704, 75750,
				  75752, 75763, 75789, 75849, 75915, 75933, 75949, 75964, 75969, 75973, 75980,
				  76023, 76055, 76060, 76066, 76088, 76119, 76226, 76239, 76247, 76271, 76380,
				  76443, 76534, 76621, 76640, 76657, 76682, 76711, 76932, 76935, 77033, 77050,
				  77053, 77078, 77336, 77354, 77363, 77389, 77396, 77466, 77496, 77517, 77561,
				  77632, 77808, 77905, 77968, 78025, 78123, 78132, 78140, 78141, 78210, 78220,
				  78239, 78242, 78333, 78335, 78343, 78368, 78370, 78383, 78407, 78535, 78574,
				  78583, 78590, 78605, 78640, 78669, 78802, 78830, 78836, 78877, 78884, 78935,
				  78960, 79010, 79107, 79108, 79114, 79118, 79311, 79367, 79408, 79411, 79511,
				  79521, 79536, 79561, 79563, 79778, 79782, 79836, 79838, 79849, 79901, 79922,
				  79934.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 134 - BENEFITS-GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS › Subchapter B - MISCELLANEOUS REIMBURSEMENT › Section 134.100 - Reimbursement of Treating Doctor for Attendance at Required Medical Examination

Current through Reg. 49, No. 28; July 12, 2024
(a) When an
				  injured employee's treating doctor is present at a required medical examination
				  in accordance with §
										126.6
				  of this title (relating to Required Medical Examination), the insurance carrier
				  shall reimburse the treating doctor for time as follows:
(1) at a rate of $100 an hour limited to four
				  hours, unless the insurance carrier pre-approves extended time; and
(2) in quarter hour increments with any
				  amount over 10 minutes considered an additional quarter hour.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 134 - BENEFITS-GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS › Subchapter B - MISCELLANEOUS REIMBURSEMENT › Section 134.110 - Reimbursement of Injured Employee for Travel Expenses Incurred

Current through Reg. 49, No. 28; July 12, 2024
(a) An injured employee may request
				  reimbursement from the insurance carrier if the injured employee has incurred
				  travel expenses when:
(1) medical treatment
				  for the compensable injury is not reasonably available within 30 miles from
				  where the injured employee lives and the distance traveled to secure medical
				  treatment is greater than 30 miles one-way; or
(2) the distance traveled to attend a
				  designated doctor examination, required medical examination, or post designated
				  doctor treating or referral doctor examination is greater than 30 miles
				  one-way.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 134 - BENEFITS-GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS › Subchapter B - MISCELLANEOUS REIMBURSEMENT › Section 134.120 - Reimbursement for Medical Documentation

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  An insurance carrier is not required to reimburse initial medical documentation
				  provided to the insurance carrier in accordance with §
										133.210 of
				  this title (relating to Medical Documentation).
(b) An insurance carrier shall separately
				  reimburse subsequent copies of medical documentation requested by the insurance
				  carrier in accordance with §
										133.210 of
				  this title.
(c) Upon request, the
				  health care provider shall provide the injured employee, or the injured
				  employee's representative, an initial copy of the medical documentation without
				  charge. The requestor shall reimburse the health care provider for subsequent
				  requests of the same medical documentation.
(d) If the injured employee, or the injured
				  employee's representative, requests creation of medical documentation, such as
				  a medical narrative, the requestor shall reimburse the health care provider for
				  this additional information.
(e)
				  The health care provider shall provide copies of any requested or required
				  documentation to the Division at no charge.
(f) The reimbursements for medical
				  documentation are:
(1) copies of medical
				  documentation--$.50 per page;
(2)
				  copies of hospital records--an initial fee of $5.00 plus $.50 per page for the
				  first 20 pages, then $.30 per page for records over 20 pages;
(3) microfilm--$.50 per page;
(4) copies of X-ray films--$8.00 per
				  film;
(5) narrative reports:
(A) one to two pages--$100;
(B) each page after two pages--$40 per
				  page.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 134 - BENEFITS-GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS › Subchapter B - MISCELLANEOUS REIMBURSEMENT › Section 134.130 - Interest for Late Payment on Medical Bills and Refunds

Current through Reg. 49, No. 28; July 12, 2024
(a) Insurance carriers shall pay interest on
				  medical bills paid on or after the 60th day after the insurance carrier
				  originally received the complete medical bill, in accordance with §
				  133.340 of this title (relating to Medical Payments and Denials).
(b) Health care providers shall pay interest
				  to insurance carriers on requests for refunds paid later than the 60th day
				  after the date the health care provider received the request for refund, in
				  accordance with §
										133.260 of
				  this title (relating to Refunds).
(c) The rate of interest to be paid shall be
				  the rate calculated in accordance with Labor Code §
										401.023
				  and in effect on the date the payment was made.
(d) Interest shall be calculated as follows:
(1) multiply the rate of interest by the
				  amount on which interest is due (to determine the annual amount of
				  interest);
(2) divide the annual
				  amount of interest by 365 (to determine the daily interest amount);
				  then
(3) multiply the daily
				  interest amount by the number of days of interest to which the recipient is
				  entitled under subsection (a) or (b) of this section.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 134 - BENEFITS-GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS › Subchapter B - MISCELLANEOUS REIMBURSEMENT › Section 134.150 - Reimbursement of Services Provided by a Federal Military Treatment Facility

Current through Reg. 49, No. 28; July 12, 2024
(a) This section applies, regardless of the
				  date of injury, to medical services provided on or after January 1, 2020, in a
				  federal military treatment facility (FMTF) as defined in Labor Code §
										413.0112(a)
				  (relating to Reimbursement of Federal Military Treatment Facility).
(b) Reimbursement for medical services
				  provided to an injured employee shall be the amount of the FMTF's charges as
				  determined under Title 32, Code of Federal Regulations, Part 220 (concerning
				  Collection of Reasonable Charges for Healthcare Services). Additionally,
				  charges may include interest, administrative penalties, or collection fees
				  related to medical benefits.
(c) An
				  FMTF is not required to comply with health care provider billing or
				  preauthorization requirements in Chapters 133 (concerning General Medical
				  Provisions) and 134 (concerning Benefits--Guidelines for Medical Services,
				  Charges, and Payments) of this title. An insurance carrier shall process a
				  medical bill from an FMTF and make payment in accordance with Chapters 133 and
				  134, except as provided in Labor Code §
										413.0112.
				  The insurance carrier shall contact the FMTF to obtain any information
				  necessary to process a medical bill and document the name and telephone number
				  of the person who supplied the information.
(d) Notwithstanding the requirements of
				  Chapter 133, an insurance carrier shall process professional and institutional
				  medical services submitted on a single bill by an FMTF. An insurance carrier
				  shall identify reimbursement for professional and institutional services
				  separately on the explanation of benefits form.
(e) The insurance carrier may only deny
				  payment of medical services provided by an FMTF for reasons of medical
				  necessity, compensability, extent of injury, or liability.
(f) An insurance carrier shall forward to the
				  division, within 14 calendar days of receipt, in the form and manner prescribed
				  by the division, the first medical bill for an injured employee that it
				  receives from an FMTF.
(g) An
				  insurance carrier shall report FMTF medical bills in accordance with Chapter
				  134, Subchapter I, of this title. FMTF medical bills are subject to §
										102.9
				  of this title (concerning Submission of Information Requested by the
				  Commission) including medical bills not reported in accordance with
				  §134.806(a)(3) (concerning Records Excluded from Reporting).
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 134 - BENEFITS-GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS › Subchapter B - MISCELLANEOUS REIMBURSEMENT › Section 134.155 - Federal Military Treatment Facility Disputes

Current through Reg. 49, No. 28; July 12, 2024
(a) Disputes over charges billed by a federal
				  military treatment facility (FMTF):
(1) If an
				  insurance carrier denies payment of a medical bill based on medical necessity,
				  the medical necessity dispute shall be initiated under §
											133.308
				  of this title (concerning MDR of Medical Necessity Disputes):
(A) Notwithstanding Chapter 133, Subchapter
				  D, of this title (concerning Dispute of Medical Bills), an injured employee is
				  not required to request reconsideration prior to requesting medical dispute
				  resolution;
(B) Notwithstanding
				  §133.308(f)(2)(B), an injured employee may be a requestor in a medical
				  necessity dispute, and
(C)
				  Notwithstanding §133.308(q), the insurance carrier shall pay all
				  independent review organization fees.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 134 - BENEFITS-GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS › Subchapter C - MEDICAL FEE GUIDELINES › Section 134.201 - Medical Fee Guideline for Medical Treatments and Services Provided under the Texas Workers' Compensation Act

Current through Reg. 49, No. 28; July 12, 2024
(a) The
				  commission adopts by reference herein, the Texas Workers' Compensation
				  Commission Medical Fee Guideline 1996. The Guideline shall be effective for all
				  medical treatments, services, durable medical equipment and pharmaceuticals
				  provided on or after April 1, 1996. Medical treatments, services, and durable
				  medical equipment provided prior to April 1, 1996, shall be subject to the 1991
				  Texas Workers' Compensation Commission Medical Fee Guideline (December 1991
				  Version). Pharmaceuticals provided prior to April 1, 1996, shall be subject to
				  §
										134.501
				  of this title (relating to the Pharmaceutical Fee Guideline). Copies of both
				  guidelines may be obtained from the Publication Department of the Texas
				  Workers' Compensation Commission, 4000 South IH-35, Southfield Building,
				  Austin, Texas 78704.
(b) An
				  insurance carrier or health care provider which willfully or intentionally
				  violates the provisions of this rule commits an administrative violation under
				  Texas Labor Code, §
										415.002
				  or §
										415.003,
				  and may be assessed a penalty. In addition, an insurance carrier or health care
				  provider which repeatedly violates these statutory provisions may be assessed a
				  penalty not to exceed $10,000 under the Texas Labor Code, §
										415.021,
				  and may be subject to the sanctions specified in the Texas Labor Code, §
										415.023,
				  including, but not limited to, restriction or revocation of the right to
				  receive reimbursement under the Texas Workers' Compensation Act.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 134 - BENEFITS-GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS › Subchapter C - MEDICAL FEE GUIDELINES › Section 134.203 - Medical Fee Guideline for Professional Services

Current through Reg. 49, No. 28; July 12, 2024
(a) Applicability of this rule is as follows:
(1) This section applies to professional
				  medical services provided in the Texas workers' compensation system, other
				  than:
(A) workers' compensation specific
				  codes, services, and programs described in §
												134.204
				  of this title (relating to Medical Fee Guideline for Workers' Compensation
				  Specific Services);
(B)
				  prescription drugs or medicine;
(C)
				  dental services;
(D) the facility
				  services of a hospital or other health care facility; and
(E) medical services provided through a
				  workers' compensation health care network certified pursuant to Insurance Code
				  Chapter 1305, except as provided in Insurance Code Chapter 1305.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 134 - BENEFITS-GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS › Subchapter C - MEDICAL FEE GUIDELINES › Section 134.204 - Medical Fee Guideline for Workers' Compensation Specific Services

Current through Reg. 49, No. 28; July 12, 2024
(a) Applicability of this rule is as follows:
(1) This section applies to workers'
				  compensation specific codes, services and programs provided in the Texas
				  workers' compensation system, other than:
(A)
				  professional medical services described in §
												134.203
				  of this title (relating to Medical Fee Guideline for Professional
				  Services);
(B) prescription drugs
				  or medicine;
(C) dental
				  services;
(D) the facility services
				  of a hospital or other health care facility; and
(E) medical services provided through a
				  workers' compensation health care network certified pursuant to Insurance Code
				  Chapter 1305, except as provided in §
												134.1 of
				  this title and Insurance Code Chapter 1305.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 134 - BENEFITS-GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS › Subchapter C - MEDICAL FEE GUIDELINES › Section 134.209 - Applicability

Current through Reg. 49, No. 28; July 12, 2024
(a) Sections
				  134.209, 134.210,
				  134.215,
				  134.220,
				  134.225,
				  134.230,
				  134.235,
				  134.239,
				  134.240,
				  134.250, and
				  134.260 of this title apply to
				  workers' compensation specific codes, services, and programs provided in the
				  Texas workers' compensation system, other than:
(1) professional medical services described
				  in §
											134.203 of this title;
(2) prescription drugs or medicine;
(3) dental services;
(4) the facility services of a hospital or
				  other health care facility; and
(5)
				  medical services provided through a workers' compensation health care network
				  certified under Insurance Code Chapter 1305, except as provided in §
											134.1 of this title and Insurance
				  Code Chapter 1305.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 134 - BENEFITS-GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS › Subchapter C - MEDICAL FEE GUIDELINES › Section 134.210 - Medical Fee Guideline for Workers' Compensation Specific Services

Current through Reg. 49, No. 28; July 12, 2024
(a) Specific
				  provisions contained in the Labor Code or division rules, including this
				  chapter, take precedence over any conflicting provision adopted or used by the
				  Centers for Medicare and Medicaid Services (CMS) in administering the Medicare
				  program. Independent review organization decisions on medical necessity made in
				  accordance with Labor Code §
										413.031 and §
										133.308 of this title, which are
				  made on a case-by-case basis, take precedence, in that case only, over any
				  division rules and Medicare payment policies.
(b) Payment policies relating to coding,
				  billing, and reporting for workers' compensation specific codes, services, and
				  programs are as follows:
(1) Health care
				  providers must bill their usual and customary charges using the most current
				  Level I Current Procedural Terminology (CPT) and Level II Healthcare Common
				  Procedure Coding System (HCPCS) codes. Health care providers must submit
				  medical bills in accordance with the Labor Code and division rules.
(2) Modifying circumstance must be identified
				  by use of the appropriate modifier following the appropriate Level I (CPT
				  codes) and Level II HCPCS codes. Where HCPCS modifiers apply, insurance
				  carriers must treat them in accordance with Medicare and Texas Medicaid rules.
				  In addition, division-specific modifiers are identified in subsection (f) of
				  this section. When two or more modifiers apply to a single HCPCS code, indicate
				  each modifier on the bill.
(3) A
				  10% incentive payment must be added to the maximum allowable reimbursement
				  (MAR) for services outlined in §§
											134.220,
				  134.225,
				  134.235,
				  134.240,
				  134.250, and
				  134.260 of this title and
				  subsection (d) of this section that are performed in designated workers'
				  compensation underserved areas in accordance with §
											134.2 of this title. However,
				  reimbursement for a missed appointment under §134.240 does not qualify for
				  the 10% incentive payment.
(4) Fees
				  established in §§
											134.235,
				  134.240,
				  134.250, and
				  134.260 of this title will be:
(A) adjusted once by applying the Medicare
				  Economic Index (MEI) percentage adjustment factor for the period 2009 -
				  2024.
(B) adjusted annually by
				  applying the MEI percentage adjustment factor identified in
				  §134.203(c)(2).
(C) rounded to
				  whole dollars by dropping amounts under 50 cents and increasing amounts from 50
				  to 99 cents to the next dollar. For example, $1.39 becomes $1 and $2.50 becomes
				  $3.
(D) effective on January 1 of
				  each new calendar year.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 134 - BENEFITS-GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS › Subchapter C - MEDICAL FEE GUIDELINES › Section 134.215 - Home Health Services

Current through Reg. 49, No. 28; July 12, 2024
The maximum allowable reimbursement (MAR) amount for home
					 health services provided through a licensed home health agency shall be 125
					 percent of the published Texas Medicaid fee schedule for home health
					 agencies.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 134 - BENEFITS-GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS › Subchapter C - MEDICAL FEE GUIDELINES › Section 134.220 - Case Management Services

Current through Reg. 49, No. 28; July 12, 2024
Case management responsibilities by the treating doctor are
					 as follows:
(1) Team conferences and
				  telephone calls shall include coordination with an interdisciplinary team.
(A) Team members shall not be employees of
				  the treating doctor.
(B) Team
				  conferences and telephone calls must be outside of an interdisciplinary
				  program. Documentation shall include the purpose and outcome of conferences and
				  telephone calls, and the name and specialty of each individual attending the
				  team conference or engaged in a phone call.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 134 - BENEFITS-GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS › Subchapter C - MEDICAL FEE GUIDELINES › Section 134.225 - Functional Capacity Evaluations

Current through Reg. 49, No. 28; July 12, 2024
The following applies to functional capacity evaluations
					 (FCEs). A maximum of three FCEs for each compensable injury shall be billed and
					 reimbursed. FCEs ordered by the division shall not count toward the three FCEs
					 allowed for each compensable injury. FCEs shall be billed using CPT code 97750
					 with modifier "FC." FCEs shall be reimbursed in accordance with §
										134.203(c)(1)
					 of this title. Reimbursement shall be for up to a maximum of four hours for the
					 initial test or for a division ordered test; a maximum of two hours for an
					 interim test; and a maximum of three hours for the discharge test, unless it is
					 the initial test. Documentation is required. FCEs shall include the following
					 elements:
(1) A physical examination
				  and neurological evaluation, which include the following:
(A) appearance (observational and
				  palpation);
(B) flexibility of the
				  extremity joint or spinal region (usually observational);
(C) posture and deformities;
(D) vascular integrity;
(E) neurological tests to detect sensory
				  deficit;
(F) myotomal strength to
				  detect gross motor deficit; and
(G)
				  reflexes to detect neurological reflex symmetry.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 134 - BENEFITS-GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS › Subchapter C - MEDICAL FEE GUIDELINES › Section 134.230 - Return to Work Rehabilitation Programs

Current through Reg. 49, No. 28; July 12, 2024
The following shall be applied to Return To Work
					 Rehabilitation Programs for billing and reimbursement of Work
					 Conditioning/General Occupational Rehabilitation Programs, Work
					 Hardening/Comprehensive Occupational Rehabilitation Programs, Chronic Pain
					 Management/Interdisciplinary Pain Rehabilitation Programs, and Outpatient
					 Medical Rehabilitation Programs. To qualify as a division Return to Work
					 Rehabilitation Program, a program should meet the specific program standards
					 for the program as listed in the most recent Commission on Accreditation of
					 Rehabilitation Facilities (CARF) Medical Rehabilitation Standards Manual, which
					 includes active participation in recovery and return to work planning by the
					 injured employee, employer and payor or insurance carrier.
(1) Accreditation by the CARF is recommended,
				  but not required.
(A) If the program is CARF
				  accredited, modifier "CA" shall follow the appropriate program modifier as
				  designated for the specific programs listed below. The hourly reimbursement for
				  a CARF accredited program shall be 100 percent of the maximum allowable
				  reimbursement (MAR).
(B) If the
				  program is not CARF accredited, the only modifier required is the appropriate
				  program modifier. The hourly reimbursement for a non-CARF accredited program
				  shall be 80 percent of the MAR.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 134 - BENEFITS-GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS › Subchapter C - MEDICAL FEE GUIDELINES › Section 134.235 - Required Medical Examinations

Current through Reg. 49, No. 28; July 12, 2024
(a) Required
				  medical examination doctors (RME doctors) must perform examinations in
				  accordance with Labor Code §§
										408.004,
				  408.0041,
				  408.0043, and
				  408.0045 and division
				  rules.
(b) Each examination and its
				  individual billable components will be billed and reimbursed
				  separately.
(c) When conducting an
				  insurance carrier-requested examination to determine impairment or attainment
				  of maximum medical improvement (MMI), the RME doctor must bill, and the
				  insurance carrier must reimburse, using CPT code 99456, with the modifiers and
				  at the rates specified in paragraphs (c)(2) - (3).
(1) The total maximum allowable reimbursement
				  (MAR) for a MMI or impairment rating (IR) examination is equal to the MMI
				  evaluation reimbursement plus the reimbursement for the body area or areas
				  evaluated for the assignment of an IR. The MMI or IR examination must include:
(A) the examination;
(B) consultation with the injured
				  employee;
(C) review of the records
				  and films;
(D) the preparation and
				  submission of reports (including the narrative report and responding to the
				  need for further clarification, explanation, or reconsideration), calculation
				  tables, figures, and worksheets; and
(E) tests used to assign the IR, as outlined
				  in the American Medical Association Guides to the Evaluation of Permanent
				  Impairment (AMA Guides), as stated in the Labor Code and Chapter 130 of this
				  title.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 134 - BENEFITS-GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS › Subchapter C - MEDICAL FEE GUIDELINES › Section 134.239 - Billing for Work Status Reports

Current through Reg. 49, No. 28; July 12, 2024
Work status reports described by §
										129.5 of this title may not be
					 billed or reimbursed separately when completed as a component of an ordered
					 examination.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 134 - BENEFITS-GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS › Subchapter C - MEDICAL FEE GUIDELINES › Section 134.240 - Designated Doctor Examinations

Current through Reg. 49, No. 28; July 12, 2024
(a) Designated
				  doctors must perform examinations in accordance with Labor Code §§
										408.004,
				  408.0041, and
				  408.151 and division
				  rules.
(b) The designated doctor
				  must bill, and the insurance carrier must reimburse, for a missed appointment
				  when the injured employee does not attend a properly scheduled or rescheduled
				  examination under 28 TAC §
										127.5(h) - (j).
(1) The designated doctor may bill for the
				  missed appointment fee when:
(A) the injured
				  employee does not attend a scheduled appointment; and
(B) the designated doctor waits at the
				  examination location for at least 30 minutes after the scheduled appointment
				  time.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 134 - BENEFITS-GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS › Subchapter C - MEDICAL FEE GUIDELINES › Section 134.250 - Maximum Medical Improvement Evaluations and Impairment Rating Examinations by Treating Doctors

Current through Reg. 49, No. 28; July 12, 2024
(a) The total
				  maximum allowable reimbursement (MAR) for a maximum medical improvement (MMI)
				  or impairment rating (IR) examination is equal to the MMI evaluation
				  reimbursement plus the reimbursement for the body area or areas evaluated for
				  the assignment of an IR. The MMI or IR examination must include:
(1) the examination;
(2) consultation with the injured
				  employee;
(3) review of the records
				  and films;
(4) the preparation and
				  submission of reports (including the narrative report and responding to the
				  need for further clarification, explanation, or reconsideration), calculation
				  tables, figures, and worksheets; and
(5) tests used to assign the IR, as outlined
				  in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), as
				  stated in the Labor Code and Chapter 130 of this title.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 134 - BENEFITS-GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS › Subchapter C - MEDICAL FEE GUIDELINES › Section 134.260 - Maximum Medical Improvement Evaluations and Impairment Rating Examinations by Referred Doctors

Current through Reg. 49, No. 28; July 12, 2024
(a) The total
				  maximum allowable reimbursement (MAR) for a maximum medical improvement (MMI)
				  or impairment rating (IR) examination is equal to the MMI evaluation
				  reimbursement plus the reimbursement for the body area or areas evaluated for
				  the assignment of an IR. The MMI or IR examination must include:
(1) the examination;
(2) consultation with the injured
				  employee;
(3) review of the records
				  and films;
(4) the preparation and
				  submission of reports (including the narrative report and responding to the
				  need for further clarification, explanation, or reconsideration), calculation
				  tables, figures, and worksheets; and
(5) tests used to assign the IR, as outlined
				  in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), as
				  stated in the Labor Code and Chapter 130 of this title.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 134 - BENEFITS-GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS › Subchapter C - MEDICAL FEE GUIDELINES › Section 134.303 - 2005 Dental Fee Guideline

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  Applicability of this rule is as follows:
(1)
				  This section applies to professional dental services provided in the Texas
				  Workers' Compensation system.
(2)
				  This section shall be applicable to professional dental services provided on or
				  after June 15, 2005. For professional dental services provided August 1, 2003
				  through June 14, 2005, §
											134.202
				  of this title (relating to Medical Fee Guideline) shall be applicable. For
				  professional dental services provided December 1, 1996 through July 31, 2003,
				  §
											134.302
				  of this title (relating to Dental Fee Guideline) shall be applicable.
(3) Specific provisions contained in the
				  Texas Workers' Compensation Act (the Act), or Texas Workers' Compensation
				  Commission (commission) rules, including this rule, shall take precedence over
				  any provision adopted by or utilized by Texas Medicaid in administering the
				  Texas Medicaid Dental Fee Schedule. Independent Review Organization (IRO)
				  decisions regarding medical necessity are made on a case-by-case basis. The
				  commission will monitor IRO decisions to determine whether commission
				  rulemaking action would be appropriate.
(4) Whenever a component of the Texas
				  Medicaid Dental Fee Schedule is revised and effective, use of the revised
				  component shall be required for compliance with commission rules, decisions and
				  orders for services rendered on or after the effective date of the revised
				  component.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 134 - BENEFITS-GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS › Subchapter E - HEALTH FACILITY FEES › Section 134.402 - Ambulatory Surgical Center Fee Guideline

Current through Reg. 49, No. 28; July 12, 2024
(a) Applicability of this rule is as follows:
(1) This section applies to facility services
				  provided on or after September 1, 2008 by an ambulatory surgical center (ASC),
				  other than professional medical services.
(2) This section does not apply to:
(A) professional medical services billed by a
				  health care provider not employed by the ASC, except for a surgical implant
				  provider as described in this section; or
(B) medical services provided through a
				  workers' compensation health care network certified pursuant to Insurance Code
				  Chapter 1305, except as provided in Insurance Code Chapter 1305.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 134 - BENEFITS-GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS › Subchapter E - HEALTH FACILITY FEES › Section 134.403 - Hospital Facility Fee Guideline - Outpatient

Current through Reg. 49, No. 28; July 12, 2024
(a) Applicability of this section is as
				  follows.
(1) This section applies to medical
				  services provided in an outpatient acute care hospital on or after March 1,
				  2008.
(2) This section does not
				  apply to:
(A) professional medical services
				  billed by a provider not employed by the hospital, except for a surgical
				  implant provider as described in this section; or
(B) medical services provided through a
				  workers' compensation health care network certified pursuant to Insurance Code
				  Chapter 1305, except as provided in Insurance Code Chapter 1305.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 134 - BENEFITS-GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS › Subchapter E - HEALTH FACILITY FEES › Section 134.404 - Hospital Facility Fee Guideline - Inpatient

Current through Reg. 49, No. 28; July 12, 2024
(a) Applicability of this section is as
				  follows.
(1) This section applies to medical
				  services provided in an inpatient acute care hospital with an admission date on
				  or after March 1, 2008.
(2) For
				  admission dates prior to March 1, 2008, the law and Division of Workers'
				  Compensation (Division) rules in effect for those dates of service shall
				  apply.
(3) This section does not
				  apply to:
(A) professional medical services
				  billed by a provider not employed by the hospital, except for a surgical
				  implant provider as described in this section; or
(B) medical services provided through a
				  workers' compensation health care network certified pursuant to Insurance Code
				  Chapter 1305, except as provided in Insurance Code Chapter 1305.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 134 - BENEFITS-GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS › Subchapter F - PHARMACEUTICAL BENEFITS › Section 134.500 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms, when used in this
					 subchapter, have the following meanings, unless the context clearly indicates
					 otherwise:
(1) Brand name drug--A drug
				  marketed under a proprietary, trademark-protected name.
(2) Certified workers' compensation health
				  care network (certified network)--An organization that is certified in
				  accordance with Insurance Code Chapter 1305 and department rules.
(3) Closed formulary--All available Food and
				  Drug Administration (FDA) approved prescription and nonprescription drugs
				  prescribed and dispensed for outpatient use, but excludes:
(A) drugs identified with a status of "N" in
				  the current edition of the
Official Disability Guidelines Treatment in
				  Workers' Comp
(ODG) / Appendix A,
ODG Workers' Compensation
				  Drug Formulary,
and any updates;
(B) any prescription drug created through
				  compounding prescribed before July 1, 2018 that contains a drug identified with
				  a status of "N" in the current edition of the
ODG Treatment in Workers'
				  Comp
(ODG) / Appendix A,
ODG Workers' Compensation Drug
				  Formulary,
and any updates;
(C) any prescription drug created through
				  compounding prescribed and dispensed on or after July 1, 2018; and
(D) any investigational or experimental drug
				  for which there is early, developing scientific or clinical evidence
				  demonstrating the potential efficacy of the treatment, but which is not yet
				  broadly accepted as the prevailing standard of care as defined in Labor Code
				  §
											413.014(a).
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 134 - BENEFITS-GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS › Subchapter F - PHARMACEUTICAL BENEFITS › Section 134.501 - Initial Pharmaceutical Coverage

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  For injuries which occur on or after December 1, 2002, the insurance carrier
				  (carrier) shall pay for specified pharmaceutical services sufficient for the
				  first seven days following the date of injury, regardless of issues of
				  liability for or compensability of the injury that the carrier may have, if,
				  prior to providing the pharmaceutical services, the health care provider (HCP)
				  obtains both a verification of insurance coverage, and an oral or written
				  confirmation that an injury has been reported. For purposes of this rule,
				  specified pharmaceutical services are prescription drugs and over-the-counter
				  medications prescribed by a doctor that cure or relieve the effects naturally
				  resulting from the compensable injury, promote recovery, or enhance the ability
				  of the employee to return to or retain employment.
(1) In determining the first seven days
				  following the injury, the date of the injury is not counted. The first day
				  after the date of injury shall be counted as "day one." The last day of the
				  seven-day period shall be known as "day seven."
(2) If the pharmaceutical services are
				  provided after day one, the carrier's reimbursement under this section is
				  limited to the date the pharmaceutical services were actually provided through
				  day seven. (Example: The pharmaceutical services were provided on day four. The
				  carrier's liability for payment under this section would be for pharmaceutical
				  services in an amount prescribed that would be the quantity sufficient for days
				  four, five, six and seven.)
(3)
				  Payment for the specified pharmaceutical services for the first seven days
				  following the date of injury shall be in accordance with §
											134.503 of
				  this title (relating to Reimbursement Methodology). The dispensing fee for the
				  initial prescription shall not be denied, prorated, or reduced even if the HCP
				  provided pharmaceutical services beyond the first seven days following the date
				  of injury and the carrier disputes or denies the pharmaceutical services beyond
				  the first seven days following the date of injury.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 134 - BENEFITS-GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS › Subchapter F - PHARMACEUTICAL BENEFITS › Section 134.502 - Pharmaceutical Services

Current through Reg. 49, No. 28; July 12, 2024
(a) A doctor
				  providing care to an injured employee shall prescribe for the employee
				  medically necessary prescription drugs and over-the-counter medication (OTC)
				  alternatives as clinically appropriate and applicable in accordance with
				  applicable state law and as provided by this section.
(1) It shall be indicated on the prescription
				  that the prescription is related to a workers' compensation claim.
(2) When prescribing an OTC medication
				  alternative to a prescription drug, the doctor shall indicate on the
				  prescription the appropriate strength of the medication and the approximate
				  quantity of the OTC medication that is reasonably required by the nature of the
				  compensable injury.
(3) The doctor
				  shall prescribe generic prescription drugs when available and clinically
				  appropriate. If in the medical judgment of the prescribing doctor a brand-name
				  drug is necessary, the doctor must specify on the prescription that brand-name
				  drugs be dispensed in accordance with applicable state and federal law, and
				  must maintain documentation justifying the use of the brand-name drug, in the
				  patient's medical record.
(4) The
				  doctor shall prescribe OTC medications in lieu of a prescription drug when
				  clinically appropriate.
Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 134 - BENEFITS-GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS › Subchapter F - PHARMACEUTICAL BENEFITS › Section 134.503 - Pharmacy Fee Guideline

Current through Reg. 49, No. 28; July 12, 2024
(a) Applicability
				  of this section is as follows:
(1) This
				  section applies to the reimbursement of prescription drugs and nonprescription
				  drugs or over-the-counter medications as those terms are defined in §
											134.500 of
				  this title (relating to Definitions) for outpatient use in the Texas workers'
				  compensation system, which includes claims:
(A) subject to a certified workers'
				  compensation health care network as defined in §
												134.500 of
				  this title;
(B) not subject to a
				  certified workers' compensation health care network; and
(C) subject to Labor Code §
												504.053(b)(2).