1. (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.
2. (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)
3. (c) The insurance carrier shall not change a billing code on a medical bill or reimburse health care at another billing code's value.
4. (d) The insurance carrier may request additional documentation, in accordance with §133.210 of this chapter (relating to Medical Documentation), not later than the 45th day after receipt of the medical bill to clarify the health care provider's charges.

5. (e) The insurance carrier shall send the explanation of benefits in the form and manner prescribed by the Division and indicate any interest amount paid, and the number of days on which interest was calculated. The explanation of benefits shall be sent to:

   1. (1) the health care provider when the insurance carrier makes payment or denies payment on a medical bill; and

   2. (2) the injured employee when payment is denied because the health care was:

      1. (A) determined to be unreasonable and/or unnecessary;

      2. (B) provided by a health care provider other than

         1. (i) the treating doctor selected in accordance with §408.022 of the Texas Labor Code,
         2. (ii) a health care provider that the treating doctor has chosen as a consulting or referral health care provider,
         3. (iii) a doctor performing a required medical examination in accordance with §126.5 of this title (relating to Procedure for Requesting Required Medical Examinations) and §126.6 of this title (relating to Order for Required Medical Examination), or
         4. (iv) a doctor performing a designated doctor examination in accordance with §130.6 of this title (relating to Designated Doctor Examinations for Maximum Medical Improvement and/or Impairment Ratings); or
      3. (C) unrelated to the compensable injury, in accordance with §124.2 of this title (relating to Carrier Reporting and Notification Requirements).
6. (f) When the insurance carrier pays a health care provider for health care for which the Division has not established a maximum allowable reimbursement, the insurance carrier shall explain and document the method it used to calculate the payment in accordance with §134.1 (relating to Medical Reimbursement).

7. (g) An insurance carrier shall have filed, or shall concurrently file, the applicable notice required by Labor Code §409.021, and §124.2 and §124.3 of this title (relating to Investigation of an Injury and Notice of Denial/Dispute) if the insurance carrier reduces or denies payment for health care provided based solely on the insurance carrier's belief that:

   1. (1) the injury is not compensable;
   2. (2) the insurance carrier is not liable for the injury due to lack of insurance coverage; or
   3. (3) the condition for which the health care was provided was not related to the compensable injury.
8. (h) If dissatisfied with the insurance carrier's final action, the health care provider may request reconsideration of the bill in accordance with §133.250 of this chapter (relating to Reconsideration for Payment of Medical Bills).
9. (i) If dissatisfied with the reconsideration outcome, the health care provider may request medical dispute resolution in accordance with §133.305 of this chapter (relating to Medical Dispute Resolution - General).
10. (j) Health care providers, injured employees, employers, attorneys, and other participants in the system shall not resubmit medical bills to insurance carriers after the insurance carrier has taken final action on a complete medical bill and provided an explanation of benefits except as provided in §133.250 and §133.305 of this chapter.
11. (k) All payments of medical bills that an insurance carrier makes on or after the 60th day after the date the insurance carrier originally received the complete medical bill shall include interest calculated in accordance with §134.130 of this title (relating to Interest for Late Payment on Medical Bills and Refunds), without any action taken by the Division. The interest payment shall be paid at the same time as the medical bill payment.
12. (l) When an insurance carrier remits payment to a health care provider agent, the agent shall remit to the health care provider the full amount that the insurance carrier reimburses.
13. (m) When an insurance carrier remits payment to a pharmacy processing agent, the pharmacy's reimbursement shall be made in accordance with the terms of its contract with the pharmacy processing agent.
14. (n) An insurance carrier commits an administrative violation if the insurance carrier fails to pay, reduce, deny, or notify the health care provider of the intent to audit a medical bill in accordance with Labor Code §408.027 and Division rules.

Source Note:The provisions of this §133.240 adopted to be effective May 2, 2006, 31 TexReg 3544.