1. (a) Medical reimbursement for health care services provided to injured employees subject to a workers' compensation health care network established under Insurance Code Chapter 1305 shall be made in accordance with the provisions of Insurance Code Chapter 1305, except as provided in subsection (b) of this section.
2. (b) Examinations conducted pursuant to Labor Code §§408.004, 408.0041, and 408.151 shall be reimbursed in accordance with §134.202 of this chapter (relating to Medical Fee Guideline).

3. (c) Medical reimbursement for health care not provided through a workers' compensation health care network shall be made in accordance with:

   1. (1) the Division's fee guidelines;
   2. (2) a negotiated contract; or
   3. (3) subsection (d) of this section in the absence of an applicable fee guideline.

4. (d) Fair and reasonable reimbursement:

   1. (1) is consistent with the criteria of Labor Code §413.011;
   2. (2) ensures that similar procedures provided in similar circumstances receive similar reimbursement; and
   3. (3) is based on nationally recognized published studies, published Division medical dispute decisions, and values assigned for services involving similar work and resource commitments, if available.
5. (e) The insurance carrier shall consistently apply fair and reasonable reimbursement amounts and maintain, in reproducible format, documentation of the insurance carrier's methodology(ies) establishing fair and reasonable reimbursement amounts. Upon request of the Division, an insurance carrier shall provide copies of such documentation.

Source Note:The provisions of this §134.1 adopted to be effective May 2, 2006, 31 TexReg 3561.