(a) An injured employee may request reimbursement from the insurance carrier when the injured employee has paid for health care provided for a compensable injury, unless the injured employee is liable for payment as specified in:
- (1) Insurance Code §1305.451, or
- (2) §134.504 of this title (relating to Pharmaceutical Expenses Incurred by the Injured Employee).
- (b) The injured employee's request for reimbursement shall be legible and shall include documentation or evidence (such as itemized receipts) of the amount the injured employee paid the health care provider.
- (c) The insurance carrier shall pay or deny the request for reimbursement within 45 days of the request. Reimbursement shall be made in accordance with §134.1 (relating to Medical Reimbursement).
- (d) The injured employee may seek reimbursement for any payment made above the Division fee guideline or contract amount from the health care provider who received the overpayment.
- (e) Within 45 days of a request, the health care provider shall reimburse the injured employee the amount paid above the applicable Division fee guideline or contract amount.
- (f) The injured employee may request, but is not required to request, reconsideration prior to requesting medical dispute resolution in accordance with §133.305 of this chapter (relating to Medical Dispute Resolution - General).
- (g) The insurance carrier shall submit injured employee medical billing and payment data to the Division in accordance with §134.802 of this title (relating to Insurance Carrier Medical Electronic Data Interchange to the Division).
Source Note:The provisions of this §133.270 adopted to be effective May 2, 2006, 31 TexReg 3544.