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Amend CSHB 724, Senate committee printing, by inserting the
following appropriately numbered SECTIONS in the bill and
renumbering subsequent SECTIONS of the bill accordingly:
SECTION __. Section 408.027(d), Labor Code, is amended to
read as follows:
(d) If an insurance carrier contests the compensability of
an injury and the injury is determined not to be compensable, the
carrier may recover the amounts paid for health care services from
the employee's accident or health benefit plan, or any other person
who may be obligated for the cost of the health care services. If an
accident or health insurance carrier or other person obligated for
the cost of health care services has paid for health care services
for an employee for an injury for which a workers' compensation
insurance carrier denies compensability, and the injury is later
determined to be compensable, the accident or health insurance
carrier or other person may recover the amounts paid for such
services from the workers' compensation insurance carrier. If an
accident or health insurance carrier or other person obligated for
the cost of health care services has paid for health care services
for an employee for an injury for which the workers' compensation
insurance carrier or the employer has not disputed compensability,
the accident or health insurance carrier or other person may
recover reimbursement from the insurance carrier in the manner
described by Section 409.009 or 409.0091, as applicable.
SECTION __. Subchapter A, Chapter 409, Labor Code, is
amended by adding Section 409.0091 to read as follows:
Sec. 409.0091. REIMBURSEMENT PROCEDURES FOR CERTAIN
ENTITIES. (a) In this section, "health care insurer" means an
insurance carrier and an authorized representative of an insurance
carrier, as described by Section 402.084(c-1).
(b) This section applies only to a request for reimbursement
by a health care insurer.
(c) Health care paid by a health care insurer may be
reimbursable as a medical benefit.
(d) Except as provided by Subsection (e), this section does
not prohibit or limit a substantive defense by a workers'
compensation insurance carrier that the health care paid for by the
health care insurer was not a medical benefit or not a correct
payment. A subclaimant may not be reimbursed for payment for any
health care that was previously denied by a workers' compensation
insurance carrier under:
(1) a preauthorization review of the specific service
or medical procedure; or
(2) a medical necessity review that determined the
service was not medically necessary for the treatment of a
compensable injury.
(e) It is not a defense to a subclaim by a health care
insurer that:
(1) the subclaimant has not sought reimbursement from
a health care provider or the subclaimant's insured;
(2) the subclaimant or the health care provider did
not request preauthorization under Section 413.014 or rules adopted
under that section; or
(3) the health care provider did not bill the workers'
compensation insurance carrier, as provided by Section 408.027,
before the 95th day after the date the health care for which the
subclaimant paid was provided.
(f) Subject to the time limits under Subsection (n), the
health care insurer shall provide, with any reimbursement request,
the tax identification number of the health care insurer and the
following to the workers' compensation insurance carrier, in a form
prescribed by the division:
(1) information identifying the workers' compensation
case, including:
(A) the division claim number;
(B) the name of the patient or claimant;
(C) the social security number of the patient or
claimant; and
(D) the date of the injury; and
(2) information describing the health care paid by the
health care insurer, including:
(A) the name of the health care provider;
(B) the tax identification number of the health
care provider;
(C) the date of service;
(D) the place of service;
(E) the ICD-9 code;
(F) the CPT, HCPCS, NDC, or revenue code;
(G) the amount charged by the health care
provider; and
(H) the amount paid by the health care insurer.
(g) The workers' compensation insurance carrier shall
reduce the amount of the reimbursable subclaim by any payments the
workers' compensation insurance carrier previously made to the
same health care provider for the provision of the same health care
on the same dates of service. In making such a reduction in
reimbursement to the subclaimant, the workers' compensation
insurance carrier shall provide evidence of the previous payments
made to the provider.
(h) For each medical benefit paid, the workers'
compensation insurance carrier shall pay to the health care insurer
the lesser of the amount payable under the applicable fee guideline
as of the date of service or the actual amount paid by the health
care insurer. In the absence of a fee guideline for a specific
service paid, the amount per service paid by the health care insurer
shall be considered in determining a fair and reasonable payment
under rules under this subtitle defining fair and reasonable
medical reimbursement. The health care insurer may not recover
interest as a part of the subclaim.
(i) On receipt of a request for reimbursement under this
section, the workers' compensation insurance carrier shall respond
to the request in writing not later than the 90th day after the date
on which the request is received. If additional information is
requested under Subsection (j), the workers' compensation
insurance carrier shall respond not later than the 120th day unless
the time is extended under Subsection (j).
(j) If the workers' compensation insurance carrier requires
additional information from the health care insurer, the workers'
compensation insurance carrier shall send notice to the health care
insurer requesting the additional information. The health care
insurer shall have 30 days to provide the requested information.
The workers' compensation insurance carrier and the health care
insurer may establish additional periods for compliance with this
subsection by written mutual agreement.
(k) Unless the parties have agreed to an extension of time
under Subsection (j), the health care insurer must file a written
subclaim under this section not later than the 120th day after:
(1) the workers' compensation insurance carrier fails
to respond to a request for reimbursement; or
(2) receipt of the workers' compensation insurance
carrier's notice of denial to pay or reduction in reimbursement.
(l) Any dispute that arises from a failure to respond to or a
reduction or denial of a request for reimbursement of services that
form the basis of the subclaim must go through the appropriate
dispute resolution process under this subtitle and division rules.
The commissioner of insurance and the commissioner of workers'
compensation shall modify rules under this subtitle as necessary to
allow the health care insurer access as a subclaimant to the
appropriate dispute resolution process. Rules adopted or amended
by the commissioner of insurance and the commissioner of workers'
compensation must recognize the status of a subclaimant as a party
to the dispute. Rules modified or adopted under this section should
ensure that the workers' compensation insurance carrier is not
penalized, including not being held responsible for costs of
obtaining the additional information, if the workers' compensation
insurance carrier denies payment in order to move to dispute
resolution to obtain additional information to process the request.
(m) In a dispute filed under Chapter 410 that arises from a
subclaim under this section, a hearing officer may issue an order
regarding compensability or eligibility for benefits and order the
workers' compensation insurance carrier to reimburse health care
services paid by the health care insurer as appropriate under this
subtitle. Any dispute over the amount of medical benefits owed
under this section, including medical necessity issues, shall be
determined by medical dispute resolution under Sections 413.031 and
413.032.
(n) Except as provided by Subsection (s), a health care
insurer must file a request for reimbursement with the workers'
compensation insurance carrier not later than six months after the
date on which the health care insurer received information under
Section 402.084(c-3) and not later than 18 months after the health
care insurer paid for the health care service.
(o) The commissioner and the commissioner of insurance
shall amend or adopt rules to specify the process by which an
employee who has paid for health care services described by Section
408.027(d) may seek reimbursement.
(p) Until September 1, 2011, a workers' compensation
insurance carrier is exempt from any department and division data
reporting requirements affected by a lack of information caused by
reimbursement requests or subclaims under this section. If data
reporting is required after that date, the requirement is
prospective only and may not require any data to be reported between
September 1, 2007, and the date required reporting is reinstated.
The department and the division may make legislative
recommendations to the 82nd Legislature for the collection of
reimbursement request and subclaim data.
(q) An action or failure to act by a workers' compensation
insurance carrier under this section may not serve as the basis for
an examination or administrative action by the department or the
division, or for any cause of action by any person, except for
judicial review under this subtitle.
(r) The commissioner of insurance and the commissioner of
workers' compensation may adopt additional rules to clarify the
processes required by, fulfill the purpose of, or assist the
parties in the proper adjudication of subclaims under this section.
(s) On or after September 1, 2007, from information provided
to a health care insurer before January 1, 2007, under Section
402.084(c-3), the health care insurer may file not later than March
1, 2008:
(1) a subclaim with the division under Subsection (l)
if a request for reimbursement has been presented and denied by a
workers' compensation insurance carrier; or
(2) a request for reimbursement under Subsection (f)
if a request for reimbursement has not previously been presented
and denied by the workers' compensation insurance carrier.
SECTION __. The change in law made by this Act applies only
to a subclaim based on a compensable injury that occurred on or
after September 1, 2007, and to reimbursement requests and
subclaims pursuant to Section 409.0091(s), Labor Code, as added by
this Act. The changes made by this Act apply only to subclaims
based on an injury that has not been denied for compensability or
that has been determined by the division to be compensable.
SECTION __. The commissioner of workers' compensation shall
prescribe any forms required under Section 409.0091, Labor Code, as
added by this Act, not later than September 1, 2007.
SECTION __. The commissioner of workers' compensation and
the commissioner of insurance shall adopt rules as required by this
Act not later than December 1, 2007.