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 133.305 - MDR-General

Current through Reg. 49, No. 28; July 12, 2024
(a) Definitions. The following words and
				  terms, when used in this subchapter, have the following meanings unless the
				  context clearly indicates otherwise.
(1) First
				  responder--As defined in Labor Code §
											504.055(a).
(2) Life-threatening--A disease or condition
				  for which the likelihood of death is probable unless the course of the disease
				  or condition is interrupted, as defined in Insurance Code §
											4201.002.
(3) Medical dispute resolution (MDR)--A
				  process for resolution of one or more of the following disputes:
(A) a medical fee dispute; or
(B) a medical necessity dispute, which may
				  be:
(i) a preauthorization or concurrent
				  medical necessity dispute; or
(ii)
				  a retrospective medical necessity dispute.
(4) Medical fee dispute--A dispute that
				  involves an amount of payment for non-network health care rendered to an
				  injured employee that has been determined to be medically necessary and
				  appropriate for treatment of that injured employee's compensable injury. The
				  dispute is resolved by the division pursuant to division rules, including
				  §
											133.307 of
				  this title (relating to MDR of Fee Disputes). The following types of disputes
				  can be a medical fee dispute:
(A) a health
				  care provider, or a qualified pharmacy processing agent as described in Labor
				  Code §
												413.0111,
				  dispute of an insurance carrier reduction or denial of a medical
				  bill;
(B) an injured employee
				  dispute of reduction or denial of a refund request for health care charges paid
				  by the injured employee; and
(C) a
				  health care provider dispute regarding the results of a division or insurance
				  carrier audit or review which requires the health care provider to refund an
				  amount for health care services previously paid by the insurance
				  carrier.
(5) Network
				  health care--Health care delivered or arranged by a certified workers'
				  compensation health care network, including authorized out-of-network care, as
				  defined in Insurance Code Chapter 1305 and related rules.
(6) Non-network health care--Health care not
				  delivered or arranged by a certified workers' compensation health care network
				  as defined in Insurance Code Chapter 1305 and related rules. "Non-network
				  health care" includes health care delivered pursuant to Labor Code §
											408.0281
				  and §
											408.0284.
(7) Preauthorization or concurrent medical
				  necessity dispute--A dispute that involves a review of adverse determination of
				  network or non-network health care requiring preauthorization or concurrent
				  utilization review. The dispute is reviewed by an independent review
				  organization (IRO) pursuant to the Insurance Code, the Labor Code and related
				  rules, including §
											133.308
				  of this title (relating to MDR of Medical Necessity Disputes).
(8) Requestor--The party that timely files a
				  request for medical dispute resolution with the division; the party seeking
				  relief in medical dispute resolution.
(9) Respondent--The party against whom relief
				  is sought.
(10) Retrospective
				  medical necessity dispute--A dispute that involves a review of the medical
				  necessity of health care already provided. The dispute is reviewed by an IRO
				  pursuant to the Insurance Code, Labor Code and related rules, including §
											133.308
				  of this title.
(11) Serious bodily
				  injury--As defined by §
											1.07, Penal
				  Code.
(12) State active duty--As
				  defined by §
											437.001, Government
				  Code.
(13) State training and other
				  duty--As defined by §
											437.001, Government
				  Code.
(14) Texas military
				  forces--As defined by §
											437.001, Government
				  Code.