H.B. No. 3168
AN ACT
relating to the determination of workers' compensation benefits and
the resolution of disputes regarding those benefits.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 413.031, Labor Code, is amended by
amending Subsection (e) and adding Subsection (m) to read as
follows:
(e) Except as provided by Subsections [Subsection] (d),
(f), and (m), a review of the medical necessity of a health care
service provided under this chapter or Chapter 408 shall be
conducted by an independent review organization under Article
21.58C, Insurance Code, in the same manner as reviews of
utilization review decisions by health maintenance organizations.
It is a defense for the insurance carrier if the carrier timely
complies with the decision of the independent review organization.
(m) The commission by rule may prescribe an alternate
dispute resolution process to resolve disputes regarding medical
services costing less than the cost of a review of the medical
necessity of a health care service by an independent review
organization. The cost of a review under the alternate dispute
resolution process shall be paid by the nonprevailing party.
SECTION 2. Section 408.123, Labor Code, is amended by
adding Subsections (d)-(g) to read as follows:
(d) Except as otherwise provided by this section, an
employee's first valid certification of maximum medical
improvement and first valid assignment of an impairment rating is
final if the certification or assignment is not disputed before the
91st day after the date written notification of the certification
or assignment is provided to the employee and the carrier by
verifiable means.
(e) An employee's first certification of maximum medical
improvement or assignment of an impairment rating may be disputed
after the period described by Subsection (d) if:
(1) compelling medical evidence exists of:
(A) a significant error by the certifying doctor
in applying the appropriate American Medical Association
guidelines or in calculating the impairment rating;
(B) a clearly mistaken diagnosis or a previously
undiagnosed medical condition; or
(C) improper or inadequate treatment of the
injury before the date of the certification or assignment that
would render the certification or assignment invalid; or
(2) other compelling circumstances exist as
prescribed by commission rule.
(f) If an employee has not been certified as having reached
maximum medical improvement before the expiration of 104 weeks
after the date income benefits begin to accrue or the expiration
date of any extension of benefits under Section 408.104, the
impairment rating assigned after the expiration of either of those
periods is final if the impairment rating is not disputed before the
91st day after the date written notification of the certification
or assignment is provided to the employee and the carrier by
verifiable means. A certification or assignment may be disputed
after the 90th day only as provided by Subsection (e).
(g) If an employee's disputed certification of maximum
medical improvement or assignment of impairment rating is finally
modified, overturned, or withdrawn, the first certification or
assignment made after the date of the modification, overturning, or
withdrawal becomes final if the certification or assignment is not
disputed before the 91st day after the date notification of the
certification or assignment is provided to the employee and the
carrier by verifiable means. A certification or assignment may be
disputed after the 90th day only as provided by Subsection (e).
SECTION 3. The change in law made by this Act by the
amendment of Section 408.123, Labor Code, applies only to a
certification of maximum medical improvement and assignment of an
impairment rating that is made on or after the effective date of
this Act. A certification of maximum medical improvement or
assignment of an impairment rating that is made before the
effective date of this Act is governed by the law in effect on the
date the certification or assignment was made, and the former law
is continued in effect for that purpose.
SECTION 4. This Act takes effect immediately if it receives
a vote of two-thirds of all the members elected to each house, as
provided by Section 39, Article III, Texas Constitution. If this
Act does not receive the vote necessary for immediate effect, this
Act takes effect September 1, 2003.
______________________________ ______________________________
President of the Senate Speaker of the House
I certify that H.B. No. 3168 was passed by the House on May 9,
2003, by the following vote: Yeas 137, Nays 0, 2 present, not
voting; and that the House concurred in Senate amendments to H.B.
No. 3168 on May 30, 2003, by the following vote: Yeas 141, Nays 0,
3 present, not voting.
______________________________
Chief Clerk of the House
I certify that H.B. No. 3168 was passed by the Senate, with
amendments, on May 28, 2003, by the following vote: Yeas 31, Nays
0.
______________________________
Secretary of the Senate
APPROVED: __________________
Date
__________________
Governor