1. (a) The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise:

   1. (1) Acknowledgment date--The date a document is deemed received under §102.5(d) of this title (relating to General Rules for Written Communications to and from the Commission).
   2. (2) Commission--The Texas Workers' Compensation Commission.

   3. (3) Complete medical bill--A medical bill that:

      1. (A) is submitted timely, in accordance with §134.801 of this title (relating to Submitting Medical Bills for Payment);
      2. (B) is on the Commission-prescribed form and that includes the information required by the instructions for the form;
      3. (C) includes correct billing codes from Commission fee guidelines in effect on the date(s) of service (unless the bill is a request for reimbursement by a person other than a health care provider);
      4. (D) contains supporting documentation when such documentation is specifically required by Commission rules or guidelines, unless the required documentation was previously provided to the insurance carrier or its agents; and

      5. (E) includes the following legible supporting documentation, unless previously provided to the insurance carrier or its agents:

         1. (i) for the three highest level office visits, single and interdisciplinary programs such as work conditioning programs, work hardening programs, and physical medicine treatment(s) and/or services(s): a copy of progress notes and/or SOAP (subjective/objective assessment plan/procedure) notes, which shall substantiate the care given and the need for further treatment(s) and/or services(s), and indicate progress, improvement, the date of the next treatment(s) and/or service(s), complications, and expected release dates,
         2. (ii) for surgical services rendered on the same date for which the total of the fees established in the current Commission fee guideline of greater than $500 or DOP (documentation of procedure): a copy of the operative report,
         3. (iii) for a medical bill that includes charges for the professional component of diagnostic, radiological, or pathological tests: a report on the test results, and
         4. (iv) for hospital services: an itemized statement of charges.
   4. (4) Date of service--The actual date on which a health care provider provided treatment(s) and/or service(s) to an injured employee.
   5. (5) Division--The Medical Review Division of the Texas Workers' Compensation Commission.
   6. (6) Explanation of benefits--The information an insurance carrier sends to the required parties when it makes payment or denies payment on a medical bill, and that includes, when it has reduced or denied payment on the bill, an explanation of all the reason(s) for the reduction and/or denial.

   7. (7) Emergency--Either a medical or mental health emergency as described below:

      1. (A) a medical emergency consists of the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected to result in placing the patient's health and/or bodily functions in serious jeopardy, and/or serious dysfunction of any body organ or part.
      2. (B) a mental health emergency is a condition that could reasonably be expected to present danger to self or others.

   8. (8) Fair and reasonable reimbursement--Reimbursement that meets the standards set out in §413.011 of the Texas Labor Code, and the lesser of a health care provider's usual and customary charge, or

      1. (A) the maximum allowable reimbursement, when one has been established in an applicable Commission fee guideline,
      2. (B) the determination of a payment amount for medical treatment(s) and/or service(s) for which the Commission has established no maximum allowable reimbursement amount, or
      3. (C) a negotiated contract amount.

   9. (9) Health care provider or provider--

      1. (A) an individual who is licensed to provide or render and who provides or renders health care; or
      2. (B) a nonlicensed individual who provides or renders health care under the direction or supervision of a doctor; or
      3. (C) a hospital, emergency clinic, outpatient clinic, or other facility that provides health care.

   10. (10) Insurance carrier or carrier--

       1. (A) a person authorized and admitted by the Texas Department of Insurance to do insurance business in this state under a certificate of authority that includes authorization to write workers' compensation insurance;
       2. (B) a certified self-insurer for workers' compensation insurance; or
       3. (C) or a governmental entity that self-insures, either individually or collectively.
   11. (11) Insurance carrier agent--A person or entity that the insurance carrier contracts with or utilizes for the purpose of providing claims service or fulfilling the insurance carrier's obligations under the Texas Labor Code or Commission rules.
   12. (12) Payment exception codes--The Commission-mandated codes insurance carriers use to identify the general rationale for reducing or denying payment for a properly completed medical bill.
   13. (13) Reconsideration--The second review an insurance carrier shall perform of a health care provider's medical bill or preauthorization request, in response to the health care provider's request for the second review.
   14. (14) Required medical report--A medical report, and/or narrative report that a health care provider submits in accordance with this title.
   15. (15) Retrospective review--The process of an insurance carrier reviewing health care that has been provided to an injured employee in order to determine if the health care rendered was reasonable and medically necessary and billed in accordance with the appropriate Commission fee guideline, as described in §133.301 of this title (relating to Retrospective Review of Medical Bills). The insurance carrier may perform this process manually or through automation.
   16. (16) Unbundling--Submitting bills in a fragmented way, using separate billing codes for multiple treatments or services when there is a single billing code that includes all of the treatments or services that were billed separately, or fragmenting one treatment or service into its component parts and coding each component part as if it were a separate treatment or service.
   17. (17) Upcoding--Using a diagnosis or billing code that does not best represent the injured employee's actual condition or the treatment or service actually performed.
2. (b) This rule shall apply to all dates of service on or after July 15, 2000.

Source Note:The provisions of this §133.1 adopted to be effective July 15, 2000, 25 TexReg 2115.