Amend CSSB 929 on third reading by adding the following 
appropriately numbered SECTIONs to the bill and renumbering the 
existing SECTIONs accordingly:
	SECTION __.  Subsection (d), Section 408.027, 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 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 
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 a workers' compensation carrier or employer 
accepts compensability, the accident or health insurance carrier or 
other person may recover reimbursement from the insurance carrier 
as described in Sections 409.009 and 409.0091.
	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)  This section applies only to a request for 
reimbursement by a health care insurer or authorized representative 
of a health care insurer.  For purposes of this section, "health 
care insurer" refers to an insurance carrier or an authorized 
representative of an insurance carrier described by Section 
402.084(c-1).
	(b)  Health care paid by a health care insurer is 
reimbursable as a medical benefit.  For purposes of this section, 
"Medical benefit" has the meaning assigned by Section 401.011(31).
	(c)  A request for reimbursement or subclaim of the health 
care insurer is subject to the defense that the health care paid for 
was not a medical benefit.
	(d)  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)  neither the subclaimant nor the health care 
provider obtained preauthorization under Section 413.014 or rules 
adopted under that section;
		(3)  the health care provider did not bill the 
insurance carrier, as provided by Section 408.027, by the 95th day 
after the date the health care paid for by the subclaimant was 
provided; or
		(4)  the health care provider did not comply with this 
subtitle or rules adopted under this subtitle.
	(e)  Subject to the time limits in Subsection (k), the health 
care insurer shall provide with any reimbursement request the 
following information to the insurance carrier:
		(1)  information identifying the workers' compensation 
case, including the division case number, patient/claimant name, 
patient/claimant social security number, and date of injury; and
		(2)  information describing the health care paid, 
including provider name, provider tax identification number, date 
of service, place of service, ICD-9 code, CPT code, amount charged 
by the provider, and the amount paid by the health care insurer.
	(f)  The insurance carrier shall reduce the amount of the 
reimbursable subclaim by any payments the insurance carrier had 
previously made to the same health care provider for the provision 
of the same health care on the same dates of service.  When making 
such a reduction in reimbursement to the subclaimant, the insurance 
carrier shall provide appropriate documentation of the previous 
payments.
	(g)  For each medical benefit paid, the insurance carrier 
shall pay to the health care insurer the lesser of the amount 
payable under the applicable fee guideline on the date of service or 
the actual amount paid by the health care insurer.  In the absence 
of fee guidelines for a specific service paid, the amount paid by 
the health care insurer shall be construed as a fair and reasonable 
payment under Section 413.011(d).  The health care insurer may not 
recover interest as a part of the subclaim.
	(h)  Upon receipt of a request for reimbursement under this 
section, the insurance carrier shall respond to the request in 
writing within 90 days.  If the insurance carrier refuses, fails to 
pay, or reduces a request for reimbursement under this section, the 
health care insurer may file a written claim with the division as a 
subclaimant not later than 120 days from the date of receipt of the 
carrier's notice of refusal, failure to pay, or reduction in 
reimbursement.
	(i)  A subclaimant may request dispute resolution to address 
the insurance carrier's refusal or denial of reimbursement.  The 
subclaimant must select one of the following options for dispute 
resolution:
		(1)  the subclaimant may file a dispute in accordance 
with Chapter 410; in a dispute under Chapter 410 that arises from a 
subclaim under this section or Section 408.027(d), health care 
benefits provided by a health care insurer are considered accrued 
medical benefits provided to the claimant for purposes of Section 
410.168(a)(3) and a hearing officer may award the health care 
insurer, as a subclaimant, all or part of the subclaim and may order 
the insurance carrier to pay the subclaim as part of a dispute 
adjudication process under Chapter 410; or
		(2)  the subclaimant may request dispute resolution 
under Section 413.0311; the commissioner and the commissioner of 
insurance shall adopt rules to specify the appropriate dispute 
resolution process for subclaimant disputes under Section 
413.0311.
	(j)  For a reduction in payment, a subclaimant may request 
medical dispute resolution to address the reduction in 
reimbursement under Chapter 413.  The commissioner and the 
commissioner of insurance shall adopt rules to specify the 
appropriate dispute resolution process for subclaimant disputes 
under this subsection.
	(k)  Until December 31, 2008, a health care insurer must file 
a request for reimbursement with the insurance carrier not later 
than one year from the date that the health care insurer received 
information under Section 402.084(c-3).  Effective January 1, 2009, 
a health care insurer must file a request for reimbursement with the 
insurance carrier not later than six months from the date the health 
care insurer received information under Section 402.084(c-3).  
Effective January 1, 2009, a health care insurer must file a request 
for reimbursement for a health care claim not later than the second 
anniversary of the date the claim was paid.
	SECTION __.  Subchapter C, Chapter 413, Labor Code, is 
amended by adding Section 413.0311 to read as follows:
	Sec. 413.0311.  INDEPENDENT REVIEW ORGANIZATION DISPUTE 
RESOLUTION FOR HEALTH CARE INSURER SUBCLAIMANTS.  (a)  This section 
applies to subclaimant disputes regarding reimbursements under 
Section 409.009 or 409.0091.  If an insurance carrier refuses or 
denies reimbursement, the subclaimant may request dispute 
resolution from an independent review organization.  Each 
independent review organization performing independent review must 
be certified under Chapter 4202, Insurance Code.
	(b)  Upon receipt of a denial or refusal for reimbursement, 
the subclaimant has the rights of discovery of an insurance carrier 
records or health care provider records that are available to the 
parties in a contested case hearing.
	(c)  The subclaimant shall request dispute resolution and 
present its written arguments and documentation supporting the 
determination that the paid health care services were medical 
benefits as defined under Section 401.011(31) to both the 
independent review organization and the insurance carrier.
	(d)  The insurance carrier shall make a written response to 
the independent review organization, with a copy provided to the 
subclaimant within 20 business days.
	(e)  The independent review organization shall review the 
facts and the parties' arguments and apply evidence-based medicine 
and generally accepted standards of medical care recognized in the 
medical community to determine whether the paid health care service 
constitutes a medical benefit.  The independent review organization 
shall notify the parties of its determination within 60 days of 
receipt of the initial subclaimant request for dispute resolution.
	(f)  If the independent review organization determines that 
a service is a medical benefit, the insurance carrier shall 
reimburse the subclaimant in the appropriate amount within 15 
business days.
	(g)  The independent review organization review fee shall be 
paid by the subclaimant at the time of its request for dispute 
resolution.  If the subclaimant prevails, in whole or in part in the 
dispute, the entire fee shall be reimbursed to the subclaimant by 
the insurance carrier together with the required medical benefit 
reimbursement under Subsection (f).
	SECTION __.  The change in law made by this Act applies only 
to a subclaim based on a compensable injury occurring on or after 
September 1, 2007.  A subclaim based on a compensable injury 
occurring before that date is governed by the law in effect on the 
date the injury occurred, and the former law is continued in effect 
for that purpose.  Except as otherwise provided by this Act, rules 
required to be adopted by the change in law made by this Act shall be 
adopted not later than December 31, 2007.
	SECTION __.  Any forms required under Section 409.0091, 
Labor Code, as added by this Act, shall be prescribed by the 
commissioner of workers' compensation not later than 60 days after 
the effective date of this Act.