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) Medical Dispute Resolution--a request for resolution of one or more of the following disputes after reconsideration has been requested as required by commission rules and denied by the carrier:

      1. (A) a medical fee dispute; or

      2. (B) a medical necessity dispute, which may be:

         1. (i) a prospective necessity dispute; or
         2. (ii) a retrospective necessity dispute.

   2. (2) Medical Fee Disputes--Medical Fee Disputes involve a dispute over the amount of payment for health care rendered to an injured employee and determined to be medically necessary and appropriate for treatment of that employee's compensable injury. The dispute is for reasons other than the medical necessity of the care (e.g. based upon the requirements of commission rules or fee guidelines). The dispute is resolved by the commission pursuant to commission rules, including §133.307 of this title (relating to Medical Dispute Resolution of a Medical Fee Dispute). The following types of disputes can be Medical Fee Disputes:

      1. (A) a health care provider dispute of a carrier reduction or denial of a medical bill;
      2. (B) an employee dispute of a carrier reduction or denial of a request for reimbursement of health care charges paid by the employee (employee reimbursement dispute);
      3. (C) a carrier dispute of a health care provider reduction or denial of the carrier request for refund of payment for health care previously paid by the carrier (refund request dispute); and
      4. (D) a health care provider dispute of a commission refund order issued pursuant to a commission audit or review (refund order dispute).

   3. (3) Prospective Necessity Disputes--Prospective Necessity Disputes involve a review of the medical necessity of health care requiring preauthorization or concurrent review. The dispute is reviewed by an independent review organization pursuant to commission rules, including §133.308 of this title (relating to Medical Dispute Resolution by Independent Review Organizations). The following types of disputes may be Prospective Necessity Disputes:

      1. (A) a provider or injured employee dispute of a carrier denial of preauthorization (a denial of the medical necessity of health care listed in §134.600 of this title (relating to Preauthorization, Concurrent Review, and Voluntary Certification of Health Care) made prior to the provision of the health care); or
      2. (B) a provider dispute of a carrier denial of health care pursuant to concurrent review (extension of health care beyond previously approved health care, for health care listed in §134.600 of this title.)

   4. (4) Retrospective Necessity Disputes--Retrospective Necessity Disputes involve a review of the medical necessity of health care provided. The dispute is reviewed by an independent review organization pursuant to commission rules, including §133.308 of this title. The following types of disputes may be Retrospective Necessity Disputes:

      1. (A) a health care provider dispute of a carrier denial of a medical bill based on lack of medical necessity;
      2. (B) an employee dispute of a carrier denial of a request for reimbursement of health care charges paid by the employee (employee reimbursement dispute), based on lack of medical necessity; or
      3. (C) a carrier dispute of a health care provider denial of the carrier request for refund of payment for health care previously paid by the carrier (refund request dispute).
      4. (D) a health care provider dispute of a commission refund order issued pursuant to a commission audit or review based upon lack of medical necessity (refund order dispute).
   5. (5) Requestor--the party that timely files an initial request for medical dispute resolution with the division and the carrier or respondent; the party seeking relief in medical dispute resolution.
   6. (6) Respondent--the party that files a response to all the denial reasons presented to the requestor, prior to the date the request for medical dispute resolution was filed; the party against whom relief is sought.
   7. (7) Initial request--the first request for medical dispute resolution initiated by the requestor identifying unresolved medical fee or medical necessity issues that is filed simultaneously with the respondent and the commission's Division of Medical Review (division).
2. (b) If there is a medical necessity dispute for which there are medical fee components, the requestor shall file one request for medical dispute resolution to the carrier and simultaneously file a copy with the commission for monitoring of carrier compliance pursuant to §133.308 of this title. The medical necessity dispute will be resolved prior to deciding the medical fee dispute pursuant to §133.307 of this title.

Source Note:The provisions of this §133.305 adopted to be effective January 2, 2002, 26 TexReg 10934.