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) Adverse determination--A determination by a utilization review agent that the health care services furnished or proposed to be furnished to a patient are not medically necessary, as defined in Insurance Code §4201.002.
   2. (2) Life-threatening--A disease or condition for which the likelihood of death is probable unless the course of the disease or condition is interrupted, as defined in Insurance Code §4201.002.

   3. (3) Medical dispute resolution (MDR)--A process for resolution of one or more of the following disputes:

      1. (A) a medical fee dispute; or

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

         1. (i) a preauthorization or concurrent medical necessity dispute; or
         2. (ii) a retrospective medical necessity dispute.

   4. (4) Medical fee dispute--A dispute that involves an amount of payment for non-network health care rendered to an injured employee (employee) that has been determined to be medically necessary and appropriate for treatment of that employee's compensable injury. The dispute is resolved by the Division of Workers' Compensation (Division) pursuant to Division rules, including §133.307 of this subchapter (relating to MDR of Fee Disputes). The following types of disputes can be a medical fee dispute:

      1. (A) a health care provider (provider), or a qualified pharmacy processing agent as described in Labor Code §413.0111, dispute of an insurance carrier (carrier) reduction or denial of a medical bill;
      2. (B) an employee dispute of reduction or denial of a refund request for health care charges paid by the employee; and
      3. (C) a provider dispute regarding the results of a Division or carrier audit or review which requires the provider to refund an amount for health care services previously paid by the carrier.
   5. (5) Network health care--Health care delivered or arranged by a certified workers' compensation health care network, including authorized out-of-network care, as defined in Insurance Code Chapter 1305 and related rules.
   6. (6) Non-network health care--Health care not delivered or arranged by a certified workers' compensation health care network as defined in Insurance Code Chapter 1305 and related rules. "Non-network health care" includes health care delivered pursuant to Labor Code §413.011(d-1) and §413.0115.
   7. (7) Preauthorization or concurrent medical necessity dispute--A dispute that involves a review of adverse determination of network or non-network health care requiring preauthorization or concurrent review. The dispute is reviewed by an independent review organization (IRO) pursuant to the Insurance Code, the Labor Code and related rules, including §133.308 of this subchapter (relating to MDR by Independent Review Organizations).
   8. (8) Requestor--The party that timely files a request for medical dispute resolution with the Division; the party seeking relief in medical dispute resolution.
   9. (9) Respondent--The party against whom relief is sought.
   10. (10) Retrospective medical necessity dispute--A dispute that involves a review of the medical necessity of health care already provided. The dispute is reviewed by an IRO pursuant to the Insurance Code, Labor Code and related rules, including §133.308 of this subchapter.
2. (b) Dispute Sequence. If a dispute regarding compensability, extent of injury, liability, or medical necessity exists for the same service for which there is a medical fee dispute, the disputes regarding compensability, extent of injury, liability, or medical necessity shall be resolved prior to the submission of a medical fee dispute for the same services in accordance with Labor Code §413.031 and §408.021.

3. (c) Division Administrative Fee. The Division may assess a fee, as published on the Division's website, in accordance with Labor Code §413.020 when resolving disputes pursuant to §133.307 and §133.308 of this subchapter if the decision indicates the following:

   1. (1) the provider billed an amount in conflict with Division rules, including billing rules, fee guidelines or treatment guidelines;
   2. (2) the carrier denied or reduced payment in conflict with Division rules, including reimbursement or audit rules, fee guidelines or treatment guidelines;
   3. (3) the carrier has reduced the payment based on a contracted discount rate with the provider but has not made the contract available upon the Division's request;
   4. (4) the carrier has reduced or denied payment based on a contract that indicates the direction or management of health care through a provider arrangement that has not been certified as a workers' compensation network, in accordance with Insurance Code Chapter 1305; or
   5. (5) the carrier or provider did not comply with a provision of the Insurance Code, Labor Code or related rules.
4. (d) Confidentiality. Any documentation exchanged by the parties during MDR that contains information regarding a patient other than the employee for that claim must be redacted by the party submitting the documentation to remove any information that identifies that patient.
5. (e) Severability. If a court of competent jurisdiction holds that any provision of §§133.305, 133.307, and 133.308 of this subchapter are inconsistent with any statutes of this state, are unconstitutional, or are invalid for any reason, the remaining provisions of these sections shall remain in full effect.

Source Note:The provisions of this §133.305 adopted to be effective December 31, 2006, 31 TexReg 10314; amended to be effective May 25, 2008, 33 TexReg 3954.