Court Opinion

ID: 9512835
Source: CourtListenerOpinion
Date Created: 2023-08-06 22:27:03.832795+00
Date Added: 2024-06-11T09:05:37.082142
License: Public Domain

Justice SMITH,
concurring.
The Court concludes that “a private insurance carrier’s act of reviewing medical bills and determining a reimbursement amount when no MAR has been established [does not fall] within the legal definition of a delegation.” 136 S.W.3d at 657. I agree but write separately to express my understanding that the carrier’s reimbursement determination does not constitute an administrative rule and that a de novo determination of the “fair and reasonable” reimbursement rate1 will be made in both the TWCC medical service review2 and the SOAH contested-case hearing3 without deference to the carrier’s previous reimbursement determination.

.See 28 Tex. Admin. Code § 134.1(c) (2004)("Reimbursement for services not identified in an established fee guideline shall be reimbursed at fair and reasonable rates as described in the Texas Workers’ Compensation Act, § 413.011 until such period that specific fee guidelines are established by the commission.”).

. See generally Tex. Lab.Code § 413.031.

. See Tex. Lab.Code § 413.031(k).