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 133.240 - Medical Payments and Denials

Current through Reg. 49, No. 28; July 12, 2024
(a) An insurance
				  carrier shall take final action after conducting bill review on a complete
				  medical bill, or determine to audit the medical bill in accordance with §
										133.230
				  of this chapter (relating to Insurance Carrier Audit of a Medical Bill), not
				  later than the 45th day after the date the insurance carrier received a
				  complete medical bill. An insurance carrier's deadline to make or deny payment
				  on a bill is not extended as a result of a pending request for additional
				  documentation.
(b) For health care
				  provided to injured employees not subject to a workers' compensation health
				  care network established under Insurance Code Chapter 1305, the insurance
				  carrier shall not deny reimbursement based on medical necessity for health care
				  preauthorized or voluntarily certified under Chapter 134 of this title
				  (relating to Benefits--Guidelines for Medical Services, Charges, and Payments).
				  For pharmaceutical services provided to any injured employee, the insurance
				  carrier shall not deny reimbursement based on medical necessity for
				  pharmaceutical services preauthorized or agreed to under Chapter 134,
				  Subchapter F of this title (relating to Pharmaceutical Benefits).
(c) The insurance carrier shall not change a
				  billing code on a medical bill or reimburse health care at another billing
				  code's value.
(d) The insurance
				  carrier may request additional documentation, in accordance with §
										133.210 of
				  this title (relating to Medical Documentation), not later than the 45th day
				  after receipt of the medical bill to clarify the health care provider's
				  charges.
(e) The insurance carrier
				  shall send the explanation of benefits in accordance with the elements required
				  by §
										133.500
				  and §
										133.501
				  of this title (relating to Electronic Formats for Electronic Medical Bill
				  Processing and Electronic Medical Bill Processing, respectively) if the
				  insurance carrier submits the explanation of benefits in the form of an
				  electronic remittance. The insurance carrier shall send an explanation of
				  benefits in accordance with subsection (f) of this section if the insurance
				  carrier submits the explanation of benefits in paper form. The explanation of
				  benefits shall be sent to:
(1) the health
				  care provider when the insurance carrier makes payment or denies payment on a
				  medical bill; and
(2) the injured
				  employee when payment is denied because:
(A)
				  of an adverse determination;
(B)
				  the health care was provided by a health care provider other than:
(i) the treating doctor selected in
				  accordance with Labor Code §
													408.022;
(ii) a health care provider that the treating
				  doctor has chosen as a consulting or referral health care provider;
(iii) a doctor performing a required medical
				  examination in accordance with §
													126.5
				  of this title (relating to Entitlement and Procedure for Requesting Required
				  Medical Examinations) and §
													126.6
				  of this title (relating to Required Medical Examination);
(iv) a doctor performing a designated doctor
				  examination in accordance with Labor Code §
													408.0041;
				  or
(C) the health care
				  was unrelated to the compensable injury, in accordance with §
												124.2
				  of this title (relating to Carrier Reporting and Notification
				  Requirements).
(3) the
				  prescribing doctor, if different from the health care provider identified in
				  paragraph (1) of this subsection, when payment is denied for pharmaceutical
				  services because of any reason relating to the compensability of, liability
				  for, extent of, or relatedness to the compensable injury, or for reasons
				  relating to the reasonableness or medical necessity of the pharmaceutical
				  services.