1. (a) A request for review of medical services and dispute resolution, as described in the Texas Workers' Compensation Act (the Act), §8.26, shall be submitted to the commission at the division of medical review in Austin, no later than one calendar year after the date(s) of service in dispute.
2. (b) Except where described in subsection (c) of this section, the request shall be submitted no earlier than 60 days after the insurance carrier receives the bill from the health care provider.

3. (c) The parties may submit a dispute relating to the following situations at any time the dispute arises:

   1. (1) the dispute involves denial of authorization for the provision of services that require preauthorization as described in the Act, §8.28;
   2. (2) when a second opinion on proposed spinal surgery does not concur with the recommendation of the treating doctor, as described in §133.205 of this title (relating to Commission Action When Opinions Do Not Concur); or
   3. (3) the dispute involves the entitlement to medical payments relating to issues other than the medical policies or fee guidelines.

4. (d) All documents and copies of documents submitted as part of the request shall be legible. The request shall include the following information:

   1. (1) the claimant's full name, address, and social security number;
   2. (2) the workers' compensation number assigned to the claim by the commission, if known;
   3. (3) the date and nature of the injury or illness;
   4. (4) the employer's name and address;
   5. (5) the insurance carrier's name and address;
   6. (6) the health care provider's name, address, federal tax identification number, and professional license number;
   7. (7) copies of all written communications and memoranda relating to the dispute;
   8. (8) documentation indicating efforts have been made to attempt to resolve this dispute between the parties;
   9. (9) copies of all medical bills, which are disputed, as originally submitted to the insurance carrier;
   10. (10) a summary of the requesting party's position regarding the dispute; and
   11. (11) the date of this request.
5. (e) A health care provider may request or the commission may order a peer review to review medical services related to this dispute.
6. (f) The commission may assess a fee for the review of health care treatment, fees, or charges under the Act. Additional fees may be assessed for peer review. The assumed fee will be paid by any health care provider or insurance carrier who is found to have exceeded any fee guideline or violated any medical policy of the commission. In addition, the assessed fee will be paid by any insurance carrier who is found to have unreasonably disputed a provider's charges. The schedule of charges is established in TWCC Procedure Number 5.
7. (g) On the same date of submission to the commission, the requesting party shall send a copy of the request, by certified mail, to the responding party, hereafter referred to as respondent.
8. (h) The respondent shall file a response with the commission at the division of medical review in Austin. No response shall be later than 30 days after receiving a copy of the request. A copy of this response shall be sent simultaneously to the requestor. Failure of a timely response may result in a decision against the respondent.

9. (i) The response shall include:

   1. (1) information listed in subsection (d) of this section;
   2. (2) If applicable, copies of all medical audit summaries and peer review reports that are related to this dispute, from the insurance carrier, auditing company, or peer reviewer;
   3. (3) response to the requestor's position regarding the dispute;
   4. (4) a summary of the respondent's position regarding the dispute; and
   5. (5) the date of this response.
10. (j) The commission may request additional information from either party to review the medical issues in the dispute. Requested information shall be forwarded to the division of medical review at the commission within 10 days of receipt of request.
11. (k) The division of medical review shall proceed with the review of the medical dispute after all required and requested information has been received.
12. (l) Upon completion of the review, the decision of the medical review division will be forwarded to the disputing parties, the employee, and the employee's representative.
13. (m) If the medical dispute remains unresolved after review, the parties may proceed to a hearing as described in the Act, §8.26(d).
14. (n) Request for a hearing as provided by §145.3 of this title (relating to Requesting a Hearing) shall be submitted to the division of hearings no later than 20 days from the issuance of the decision by the division of medical review.

Source Note:The provisions of this §133.305 adopted to be effective June 3, 1991, 16 TexReg 2830.