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

   1. (1) Complete request--A request for medical dispute resolution that is submitted in the form and format prescribed by the Commission.
   2. (2) Decision--The written findings and results issued by the Medical Review Division's Medical Dispute Resolution Section after reviewing the medical dispute resolution request and response.
   3. (3) Extent of injury--The damage or harm to the physical structure of the body or a disease or infection naturally resulting from the damage or harm that is a result of a compensable injury.
   4. (4) Filed--The date on which the Commission receives a request for medical dispute resolution or the Commission's chief clerk of proceedings receives a request for an administrative hearing.
   5. (5) Health care provider refund order dispute--A dispute pertaining to a refund that the Commission has ordered a health care provider to make to an insurance carrier pursuant to the Commission's findings that the amount(s) the insurance carrier paid the health care provider exceeded the Commission's guidelines and/or rules.
   6. (6) Informal resolution conference--A mediation conducted by the Medical Dispute Resolution Section when a party appeals a decision pursuant to §413.031 of the Texas Labor Code.
   7. (7) Injured employee medical reimbursement dispute--A dispute pertaining to charges an injured employee paid a health care provider for medical treatment(s) and/or service(s) that are related to a compensable injury when the insurance carrier denied the injured employee's request for reimbursement, except as provided in §133.304 of this title (relating to Medical Payments and Denials). The injured employee may only pursue reimbursement within the appropriate Commission guidelines for the amount he or she paid the health care provider.
   8. (8) Insurance carrier refund request dispute--A dispute pertaining to a refund an insurance carrier requests from a health care provider in accordance with §413.031 of the Texas Labor Code and §133.304 of this title.
   9. (9) Medical fee dispute--A dispute pertaining to the amount of payment for medical treatment(s) and/or service(s) rendered to an injured employee.
   10. (10) Medical necessity dispute--A dispute to determine whether treatment(s) and/or service(s) rendered to an injured employee was reasonable and necessary.
   11. (11) Party--A health care provider, an injured employee, or an insurance carrier, acting as a requestor or respondent in a medical dispute.
   12. (12) Peer review--An evaluation of medical documentation ordered by the Division.
   13. (13) Preauthorization dispute--A dispute pertaining to an insurance carrier's or insurance carrier's agent's denial of preauthorization.
   14. (14) Requestor--The party that files a request for medical dispute resolution with the Commission; the party seeking relief in a medical dispute. A requestor shall include all the components required by the TWCC-60a and subsection (e) of this section in its request.
   15. (15) Required medical examination--An examination ordered by the Division to resolve all or some of the issues involved in a medical dispute.
   16. (16) Respondent--The party responding to the issue(s) raised by the requestor in a medical dispute after the request has been filed with the Commission; the party against whom relief is being sought. A respondent shall include all the components required by the TWCC-60b and subsection (i) of this section in its response.

2. (b) The following individuals and entities may be parties in the medical dispute resolution process.

   1. (1) Health care provider refund order dispute. A health care provider or insurance carrier may request resolution of a dispute resulting from a refund order from the Commission. The parties to a refund order dispute are the health care provider that the Commission has ordered to make a refund and the insurance carrier to which the Commission has ordered the health care provider to make the refund, if the insurance carrier chooses to become a party.
   2. (2) Injured employee medical reimbursement dispute. An injured employee may request resolution for an injured employee medical reimbursement dispute. The parties to an injured employee medical reimbursement dispute are the injured employee seeking reimbursement and the insurance carrier that reduced or denied the request for reimbursement.
   3. (3) Insurance carrier refund request dispute. An insurance carrier may request resolution of an insurance carrier refund request dispute. The parties to an insurance carrier refund request dispute are the insurance carrier that has requested a refund from a health care provider and the health care provider.
   4. (4) Medical fee dispute. A health care provider may request resolution for a medical fee dispute. The parties to a medical fee dispute are the health care provider seeking payment of the disputed medical bill(s) and the insurance carrier that denied or reduced payment.
   5. (5) Medical necessity dispute. A health care provider may request resolution of a medical necessity dispute. The parties in a medical necessity dispute are the health care provider seeking the review and the insurance carrier that reduced or denied payment to the health care provider.
   6. (6) Preauthorization dispute. The treating doctor, the treating doctor's designee, or an injured employee may request resolution for a preauthorization dispute. The parties to a preauthorization dispute are the individual who submitted the request for medical dispute resolution and/or the injured employee, and the insurance carrier that denied preauthorization.

3. (c) Before a party may request medical dispute resolution in a medical fee, medical necessity, or preauthorization dispute, the party shall request that the insurance carrier reconsider its decision regarding the disputed issues. The requestor shall document its request for reconsideration from the insurance carrier. The insurance carrier shall respond to the request for reconsideration:

   1. (1) in accordance with §133.304 for medical fee and medical necessity disputes; and
   2. (2) within 7 days for preauthorization disputes.

4. (d) Requests for medical dispute resolution shall be filed timely with the Division. A requestor that fails to file a request for medical dispute resolution timely waives the right to medical dispute resolution. For the purpose of this section, a request is filed timely if it meets the time frames set forth below.

   1. (1) A party shall file a request for medical fee, medical necessity, or injured employee medical reimbursement dispute resolution with the Division not later than one year after the date(s) of service in dispute.
   2. (2) A health care provider shall file a request for a medical fee or medical necessity dispute with the Division no earlier than sixty days after the insurance carrier received the bill(s) for the disputed service(s), unless the insurance carrier has completed its audit of the disputed bill(s) earlier than 60 days from the date of receipt and has either denied or reduced payment to the health care provider.
   3. (3) An insurance carrier that requests medical dispute resolution for a refund request the insurance carrier sent to a health care provider shall file a request with the Division not later than one year from the insurance carrier's date stamp indicating when the insurance carrier received the complete medical bill, or, absent the insurance carrier's date stamp, not later than one year after the date(s) of service in dispute.
   4. (4) A health care provider or insurance carrier that disputes a refund order made by the Commission shall file a request with the Division not later than 20 days after the date the health care provider received the refund order.
   5. (5) A party that disputes an insurance carrier's preauthorization denial shall file a request with the Division not later than 45 days after the date the insurance carrier or its preauthorization agent denied the party's request for reconsideration for preauthorization or, upon reconsideration, denied approval for the requested treatment(s) and/or service(s).

5. (e) All requests for medical dispute resolution shall be made on the form and in the manner prescribed by the Commission. The requestor shall not submit duplicates of documents.

   1. (1) All requests shall be legible and include:

      1. (A) documentation of the request for and response to, or failure of the respondent to respond to, reconsideration, where applicable, in accordance with subsection (c) of this section;
      2. (B) a copy of all medical bill(s) relevant to the dispute, as originally submitted to the insurance carrier for reimbursement, where applicable;
      3. (C) a copy of all medical audit summaries and/or explanations of benefits, TWCC-62 form(s), and peer review report(s) relevant to the dispute, where applicable;
      4. (D) a copy of medical records, clinical notes, diagnostic test results, treatment plans, and other documents relevant to the dispute;

      5. (E) a statement of the disputed issue(s), which shall include:

         1. (i) a description of the medical treatment(s) and/or services(s) in dispute,
         2. (ii) a statement of the reasons that the disputed medical treatment(s) and/or service(s) should be preauthorized or reimbursed,
         3. (iii) a discussion of how the Texas Labor Code and Commission rules, including treatment guidelines and fee guidelines, impact the disputed issues, and
         4. (iv) a discussion regarding how the submitted documentation supports the requestor's position for each disputed issue;
      6. (F) if the dispute involves treatment(s) and/or service(s) for which the Commission has not established a maximum allowable reimbursement, documentation that discusses, demonstrates, and justifies that the payment amount being sought is a fair and reasonable rate of reimbursement in accordance with §133.1 (relating to Definitions for Chapter 133, Benefits-Medical Benefits);
      7. (G) if the dispute involves medical fees or medical necessity, a table of disputed services in the form and manner prescribed by the Commission;
      8. (H) if the dispute involves preauthorization, a copy of the insurance carrier's approval or denial for the preauthorization of treatment(s) and/or service(s) that are in dispute;
      9. (I) if the dispute involves preauthorization regarding specific durable medical equipment, i.e. orthopaedic mattress or treadmill, a copy of product literature and an invoice indicating the amount the equipment provider will charge for the purchase of the item; and

      10. (J) if the requestor is an injured employee seeking medical dispute resolution, in addition to applicable documentation listed in subsection (e) of this section,

          1. (i) proof of payment for any treatment(s) and/or service(s) for which the injured employee is seeking reimbursement, and

          2. (ii) a letter from the injured employee's treating doctor, which includes:

             1. (I) a discussion of the type of medical treatment(s) and/or service(s) in dispute, and
             2. (II) a statement regarding the medical necessity of the disputed medical treatment(s) and/or service(s).

   2. (2) The Division shall deem a request to be not properly filed if:

      1. (A) the request is not filed in the form and format prescribed by the Commission,
      2. (B) the request does not contain all the information required for the request, or
      3. (C) the request is not filed within the time frames required by subsection (d) of this section. The Division shall deem the request to be filed on the date the Division receives the complete request.
6. (f) A requestor may request, or the Commission may order, a peer review of medical services related to the dispute. The Division shall assess a fee for the peer review as described in subsection (g) of this section.
7. (g) The Commission may assess a fee for the review of health care treatment, fees, or charges as allowed by law and/or Commission rules and procedures.

8. (h) The requesting party shall file two copies of the complete request with the Division.

   1. (1) When the respondent is an insurance carrier, the Division shall forward a copy of the request to the insurance carrier. The Division shall deem the insurance carrier to have received the request on the acknowledgment date as defined in §133.1 of this title (relating to Definitions for Chapter 133, Benefits--Medical Benefits). If the Division forwards the request to the insurance carrier via its Austin representative, the representative shall sign for the request.
   2. (2) When the respondent is a health care provider, the Division shall forward a copy of the request to the health care provider by regular U.S. mail service. The Division shall deem the health care provider to have received the request on the acknowledgment date as defined in §133.1 of this title.

9. (i) The respondent shall file a response with the Division. The respondent shall not submit duplicates of documents. All responses to a request for medical dispute resolution shall be made on the form and in the manner prescribed by the Commission.

   1. (1) All responses shall be legible and include:

      1. (A) documentation of the request for and response to reconsideration, where applicable, in accordance with subsection (c) of this section;
      2. (B) a copy of all medical bill(s) relevant to the dispute, as originally submitted to the insurance carrier for reimbursement, where applicable;
      3. (C) a copy of all medical audit summaries and/or explanations of benefits, TWCC-62 form(s), and peer review report(s) relevant to the dispute, where applicable;
      4. (D) a copy of the relevant TWCC-60a, Request for Medical Dispute Resolution;
      5. (E) a copy of medical records, clinical notes, diagnostic test results, treatment plans, and other documents relevant to the dispute;

      6. (F) a statement of the disputed issue(s), which shall include:

         1. (i) a description of the medical treatment(s) and/or services(s) in dispute,
         2. (ii) a statement of the reasons that the disputed medical treatment(s) and/or service(s) should not be preauthorized or reimbursed,
         3. (iii) a discussion of how the Texas Labor Code and Commission rules, including treatment guidelines and fee guidelines, impact the disputed issues, and
         4. (iv) a discussion regarding how the submitted documentation supports the respondent's position for each disputed issue;
      7. (G) if the dispute involves treatment(s) and/or service(s) for which the Commission has not established a maximum allowable reimbursement, documentation that discusses, demonstrates, and justifies that the amount the respondent paid is a fair and reasonable rate of reimbursement in accordance with §133.1 of this title;
      8. (H) if the dispute involves medical fees or medical necessity, a table of disputed services in the form and manner prescribed by the Commission; and

      9. (I) if the dispute involves preauthorization, documentation relevant to the treatment(s) and/or service(s) in dispute:

         1. (i) a copy of written denials of preauthorization;
         2. (ii) a copy of relevant peer review reports;
         3. (iii) the reviewer's clinical rationale for denial; and
         4. (iv) the reviewer's name and specialty.

   2. (2) The Division shall deem a response to be not properly filed if:

      1. (A) the response is not filed in the form and format prescribed by the Commission,
      2. (B) the response does not contain all the information required for the response, or
      3. (C) the response is not filed within the time frames required by subsection (j) of this section. The Division shall deem the response to be filed on the date the Division receives the response.

10. (j) The Division shall not consider an untimely response from the respondent. If the response is incomplete, the respondent may amend and resubmit the response to include all the required components, as long as the amended response is filed within the time frames required by this subsection. If the respondent does not respond timely, the Division shall make and enter a decision based on the request. A party responding to a request for medical dispute resolution shall file its response no later than:

    1. (1) seven days after receipt of a copy of the request for resolution of a preauthorization dispute; or
    2. (2) 14 days after receipt of a copy of the request for resolution of all other types of disputes.
11. (k) The Commission may request additional information from either party to review the medical issues in a dispute. The party shall forward the requested information to the Division within 10 days of receipt of the request.
12. (l) The Division may require an injured employee to attend a required medical examination (RME) in accordance with §126.5 of this title (relating to Procedure for Requesting Required Medical Examinations). The treating doctor and insurance carrier shall forward a copy of all medical records, diagnostic reports, films, and other medical documents to the RME doctor appointed by the Division, to arrive no later than three days prior to the scheduled examination. Neither party may communicate with the RME doctor regarding issues not related to the medical dispute. The RME doctor shall complete a report and file it with the Division, in the form and manner prescribed by the Commission, no later than seven days after completing the examination. The RME doctor's report shall address all issues the Commission instructed the doctor to address.

13. (m) The Division may dismiss a request when:

    1. (1) the requestor informs the Division or the Division otherwise determines that the dispute no longer exists;
    2. (2) the injured employee refuses or fails to attend, without good cause, a required medical examination ordered by the Division;
    3. (3) the individual or entity requesting medical dispute resolution is not a party to the dispute as defined by subsection (b) of this section;
    4. (4) the Division determines that the medical bills in the dispute have not been properly submitted to the insurance carrier;
    5. (5) in a preauthorization dispute, the Division determines that the proposed medical treatment(s) and/or service(s) do not require preauthorization, or that preauthorization was required and was not sought, or that preauthorization was required and was approved by the insurance carrier;
    6. (6) the requestor did not file the request for medical dispute resolution timely, as required by subsection (d) of this section;
    7. (7) the request for medical dispute resolution does not contain all the components required by the TWCC-60a form and by subsection (e) of this section, in which case the requestor may amend and resubmit the request to include all the required components as long as the amended request is filed within the time frames required by subsection (d) of this section; or
    8. (8) the Division determines that good cause exists to dismiss the request.
14. (n) When the insurance carrier has raised a dispute pertaining to liability for the claim, compensability, or extent of injury, in accordance with §124.2 of this title (relating to Carrier Reporting and Notification Requirements), the Division shall adjudicate the medical dispute issues and enter a decision on those issues. The Division shall refer the issues of liability for the claim, compensability, or extent of injury to the appropriate authority for adjudication.
15. (o) Upon completion of the review, the Division shall forward its decision to the parties to the dispute.

16. (p) A party to a medical dispute may appeal the Division's decision. The party shall file a written request for a hearing with the Division of Hearings in accordance with §148.3 of this title (relating to Requesting a Hearing), no later than 20 days from the date the party received the Division's decision.

    1. (1) For the purpose of determining the date an insurance carrier has received the Division's decision, the date of receipt of the decision shall be the acknowledgment date as defined in §133.1 of this title. The insurance carrier representative shall sign for the decision.
    2. (2) The party appealing the Division's decision shall deliver a copy of its written request for a hearing to all other parties involved in the dispute.
17. (q) The Division may schedule an informal resolution conference when a disputing party files a timely request for a hearing.
18. (r) This rule shall apply to all disputes for which the initial request was submitted on or after July 15, 2000.

Source Note:The provisions of this §133.305 adopted to be effective July 15, 2000, 25 TexReg 2115.