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AN ACT
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relating to workers' compensation claims for certain medical |
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benefits, death benefits, and burial benefits. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Section 413.031, Labor Code, is amended by |
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amending Subsection (k) and adding Subsections (k-1) and (k-2) to |
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read as follows: |
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(k) A [Except as provided by Subsection (l), a] party to a |
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medical dispute, other than a medical dispute regarding spinal |
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surgery subject to Subsection (l) and a dispute subject to Section |
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413.0311, that remains unresolved after a review of the medical |
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service under this section is entitled to a hearing. A hearing |
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under this subsection shall be conducted by the State Office of |
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Administrative Hearings not later than the 60th day after the date |
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on which the party notifies the division of the request for a |
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hearing. The hearing shall be conducted in the manner provided for |
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a contested case under Chapter 2001, Government Code. |
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(k-1) A party who has exhausted all administrative remedies |
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under Subsection (k) and who is aggrieved by a final decision of the |
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State Office of Administrative Hearings may seek judicial review of |
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the decision. Judicial review under this subsection shall be |
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conducted in the manner provided for judicial review of a contested |
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case under Subchapter G, Chapter 2001, Government Code. |
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(k-2) The division and the department are not considered to |
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be parties to the medical dispute for purposes of Subsections (k) |
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and (k-1) [this subsection.
Judicial review under this subsection
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shall be conducted in the manner provided for judicial review of
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contested cases under Subchapter G, Chapter 2001, Government Code]. |
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SECTION 2. Subchapter C, Chapter 413, Labor Code, is |
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amended by adding Section 413.0311 to read as follows: |
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Sec. 413.0311. REVIEW OF CERTAIN MEDICAL DISPUTES; |
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CONTESTED CASE HEARING. (a) This section applies only to the |
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following medical disputes that remain unresolved after any |
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applicable review under Sections 413.031(b) through (i): |
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(1) a medical fee dispute in which the amount of |
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reimbursement sought by the requestor in its request for medical |
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dispute resolution does not exceed $2,000; |
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(2) an appeal of an independent review organization |
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decision regarding determination of the retrospective medical |
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necessity for a health care service for which the amount billed does |
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not exceed $3,000; and |
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(3) an appeal of an independent review organization |
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decision regarding determination of the concurrent or prospective |
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medical necessity for a health care service. |
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(b) A party to a medical dispute described by Subsection (a) |
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is entitled to a contested case hearing. A contested case hearing |
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under this section shall be conducted by a hearings officer in the |
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manner provided for contested case hearings under Subchapter D, |
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Chapter 410. Notwithstanding Section 410.024, a benefit review |
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conference is not a prerequisite to a contested case hearing under |
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this section. |
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(c) The decision of a hearings officer under this section is |
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final in the absence of a timely appeal by a party for judicial |
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review under Subsection (d). |
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(d) A party who has exhausted all administrative remedies |
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under Section 413.031 and this section and who is aggrieved by a |
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final decision of the hearings officer under Subsection (c) may |
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seek judicial review of the decision. Judicial review under this |
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subsection shall be conducted in the manner provided for judicial |
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review of a contested case under Subchapter G, Chapter 2001, |
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Government Code. |
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(e) The division and the department are not considered to be |
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parties to the medical dispute for purposes of this section. |
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SECTION 3. Section 402.073(b), Labor Code, is amended to |
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read as follows: |
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(b) In a case in which a hearing is conducted by the State |
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Office of Administrative Hearings under Section 413.031, 413.055, |
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or 415.034, the administrative law judge who conducts the hearing |
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for the State Office of Administrative Hearings shall enter the |
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final decision in the case after completion of the hearing. |
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SECTION 4. Section 408.027(d), Labor Code, is amended to |
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read as follows: |
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(d) If an insurance carrier contests the compensability of |
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an injury and the injury is determined not to be compensable, the |
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carrier may recover the amounts paid for health care services from |
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the employee's accident or health benefit plan, or any other person |
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who may be obligated for the cost of the health care services. If an |
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accident or health insurance carrier or other person obligated for |
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the cost of health care services has paid for health care services |
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for an employee for an injury for which a workers' compensation |
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insurance carrier denies compensability, and the injury is later |
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determined to be compensable, the accident or health insurance |
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carrier or other person may recover the amounts paid for such |
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services from the workers' compensation insurance carrier. If an |
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accident or health insurance carrier or other person obligated for |
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the cost of health care services has paid for health care services |
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for an employee for an injury for which the workers' compensation |
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insurance carrier or the employer has not disputed compensability, |
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the accident or health insurance carrier or other person may |
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recover reimbursement from the insurance carrier in the manner |
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described by Section 409.009 or 409.0091, as applicable. |
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SECTION 5. Section 408.182, Labor Code, is amended by |
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adding Subsections (d-1) and (d-2) and amending Subsection (e) to |
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read as follows: |
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(d-1) If there is no eligible spouse, no eligible child, and |
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no eligible grandchild, and there are no surviving dependents of |
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the deceased employee who are parents, siblings, or grandparents of |
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the deceased, the death benefits shall be paid in equal shares to |
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surviving eligible parents of the deceased. A payment of death |
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benefits made under this subsection may not exceed one payment per |
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household and may not exceed 104 weeks. |
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(d-2) Except as otherwise provided by this subsection, to |
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be eligible to receive death benefits under Subsection (d-1), an |
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eligible parent must file with the division a claim for those |
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benefits not later than the first anniversary of the date of the |
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injured employee's death from the compensable injury. The claim |
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must designate all eligible parents and necessary information for |
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payment to the eligible parents. The insurance carrier is not |
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liable for payment to any eligible parent not designated on the |
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claim. The commissioner may extend the time for filing a claim |
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under this subsection only if the eligible parent submits proof |
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satisfactory to the commissioner of a compelling reason for the |
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delay. |
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(e) If an employee is not survived by legal beneficiaries or |
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eligible parents, the death benefits shall be paid to the |
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subsequent injury fund under Section 403.007. |
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SECTION 6. Section 408.182(f), Labor Code, is amended by |
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adding Subdivision (4) to read as follows: |
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(4) "Eligible parent" means the mother or the father |
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of a deceased employee, including an adoptive parent or a |
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stepparent, who receives burial benefits under Section 408.186. |
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The term does not include a parent whose parental rights have been |
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terminated. |
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SECTION 7. Section 408.183, Labor Code, is amended by |
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adding Subsection (f-1) to read as follows: |
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(f-1) An eligible parent who is not a surviving dependent of |
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the deceased employee is entitled to receive death benefits until |
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the earlier of: |
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(1) the date the eligible parent dies; or |
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(2) the date of the expiration of 104 weeks of death |
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benefit payments. |
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SECTION 8. Subchapter A, Chapter 409, Labor Code, is |
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amended by adding Section 409.0091 to read as follows: |
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Sec. 409.0091. REIMBURSEMENT PROCEDURES FOR CERTAIN |
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ENTITIES. (a) In this section, "health care insurer" means an |
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insurance carrier and an authorized representative of an insurance |
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carrier, as described by Section 402.084(c-1). |
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(b) This section applies only to a request for reimbursement |
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by a health care insurer. |
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(c) Health care paid by a health care insurer may be |
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reimbursable as a medical benefit. |
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(d) Except as provided by Subsection (e), this section does |
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not prohibit or limit a substantive defense by a workers' |
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compensation insurance carrier that the health care paid for by the |
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health care insurer was not a medical benefit or not a correct |
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payment. A subclaimant may not be reimbursed for payment for any |
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health care that was previously denied by a workers' compensation |
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insurance carrier under: |
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(1) a preauthorization review of the specific service |
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or medical procedure; or |
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(2) a medical necessity review that determined the |
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service was not medically necessary for the treatment of a |
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compensable injury. |
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(e) It is not a defense to a subclaim by a health care |
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insurer that: |
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(1) the subclaimant has not sought reimbursement from |
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a health care provider or the subclaimant's insured; |
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(2) the subclaimant or the health care provider did |
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not request preauthorization under Section 413.014 or rules adopted |
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under that section; or |
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(3) the health care provider did not bill the workers' |
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compensation insurance carrier, as provided by Section 408.027, |
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before the 95th day after the date the health care for which the |
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subclaimant paid was provided. |
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(f) Subject to the time limits under Subsection (n), the |
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health care insurer shall provide, with any reimbursement request, |
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the tax identification number of the health care insurer and the |
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following to the workers' compensation insurance carrier, in a form |
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prescribed by the division: |
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(1) information identifying the workers' compensation |
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case, including: |
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(A) the division claim number; |
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(B) the name of the patient or claimant; |
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(C) the social security number of the patient or |
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claimant; and |
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(D) the date of the injury; and |
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(2) information describing the health care paid by the |
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health care insurer, including: |
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(A) the name of the health care provider; |
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(B) the tax identification number of the health |
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care provider; |
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(C) the date of service; |
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(D) the place of service; |
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(E) the ICD-9 code; |
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(F) the CPT, HCPCS, NDC, or revenue code; |
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(G) the amount charged by the health care |
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provider; and |
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(H) the amount paid by the health care insurer. |
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(g) The workers' compensation insurance carrier shall |
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reduce the amount of the reimbursable subclaim by any payments the |
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workers' compensation insurance carrier previously made to the |
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same health care provider for the provision of the same health care |
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on the same dates of service. In making such a reduction in |
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reimbursement to the subclaimant, the workers' compensation |
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insurance carrier shall provide evidence of the previous payments |
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made to the provider. |
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(h) For each medical benefit paid, the workers' |
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compensation insurance carrier shall pay to the health care insurer |
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the lesser of the amount payable under the applicable fee guideline |
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as of the date of service or the actual amount paid by the health |
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care insurer. In the absence of a fee guideline for a specific |
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service paid, the amount per service paid by the health care insurer |
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shall be considered in determining a fair and reasonable payment |
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under rules under this subtitle defining fair and reasonable |
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medical reimbursement. The health care insurer may not recover |
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interest as a part of the subclaim. |
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(i) On receipt of a request for reimbursement under this |
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section, the workers' compensation insurance carrier shall respond |
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to the request in writing not later than the 90th day after the date |
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on which the request is received. If additional information is |
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requested under Subsection (j), the workers' compensation |
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insurance carrier shall respond not later than the 120th day unless |
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the time is extended under Subsection (j). |
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(j) If the workers' compensation insurance carrier requires |
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additional information from the health care insurer, the workers' |
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compensation insurance carrier shall send notice to the health care |
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insurer requesting the additional information. The health care |
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insurer shall have 30 days to provide the requested information. |
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The workers' compensation insurance carrier and the health care |
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insurer may establish additional periods for compliance with this |
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subsection by written mutual agreement. |
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(k) Unless the parties have agreed to an extension of time |
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under Subsection (j), the health care insurer must file a written |
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subclaim under this section not later than the 120th day after: |
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(1) the workers' compensation insurance carrier fails |
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to respond to a request for reimbursement; or |
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(2) receipt of the workers' compensation insurance |
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carrier's notice of denial to pay or reduction in reimbursement. |
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(l) Any dispute that arises from a failure to respond to or a |
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reduction or denial of a request for reimbursement of services that |
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form the basis of the subclaim must go through the appropriate |
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dispute resolution process under this subtitle and division rules. |
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The commissioner of insurance and the commissioner of workers' |
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compensation shall modify rules under this subtitle as necessary to |
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allow the health care insurer access as a subclaimant to the |
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appropriate dispute resolution process. Rules adopted or amended |
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by the commissioner of insurance and the commissioner of workers' |
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compensation must recognize the status of a subclaimant as a party |
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to the dispute. Rules modified or adopted under this section should |
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ensure that the workers' compensation insurance carrier is not |
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penalized, including not being held responsible for costs of |
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obtaining the additional information, if the workers' compensation |
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insurance carrier denies payment in order to move to dispute |
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resolution to obtain additional information to process the request. |
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(m) In a dispute filed under Chapter 410 that arises from a |
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subclaim under this section, a hearing officer may issue an order |
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regarding compensability or eligibility for benefits and order the |
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workers' compensation insurance carrier to reimburse health care |
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services paid by the health care insurer as appropriate under this |
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subtitle. Any dispute over the amount of medical benefits owed |
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under this section, including medical necessity issues, shall be |
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determined by medical dispute resolution under Sections 413.031 and |
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413.032. |
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(n) Except as provided by Subsection (s), a health care |
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insurer must file a request for reimbursement with the workers' |
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compensation insurance carrier not later than six months after the |
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date on which the health care insurer received information under |
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Section 402.084(c-3) and not later than 18 months after the health |
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care insurer paid for the health care service. |
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(o) The commissioner and the commissioner of insurance |
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shall amend or adopt rules to specify the process by which an |
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employee who has paid for health care services described by Section |
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408.027(d) may seek reimbursement. |
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(p) Until September 1, 2011, a workers' compensation |
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insurance carrier is exempt from any department and division data |
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reporting requirements affected by a lack of information caused by |
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reimbursement requests or subclaims under this section. If data |
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reporting is required after that date, the requirement is |
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prospective only and may not require any data to be reported between |
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September 1, 2007, and the date required reporting is reinstated. |
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The department and the division may make legislative |
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recommendations to the 82nd Legislature for the collection of |
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reimbursement request and subclaim data. |
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(q) An action or failure to act by a workers' compensation |
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insurance carrier under this section may not serve as the basis for |
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an examination or administrative action by the department or the |
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division, or for any cause of action by any person, except for |
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judicial review under this subtitle. |
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(r) The commissioner of insurance and the commissioner of |
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workers' compensation may adopt additional rules to clarify the |
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processes required by, fulfill the purpose of, or assist the |
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parties in the proper adjudication of subclaims under this section. |
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(s) On or after September 1, 2007, from information provided |
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to a health care insurer before January 1, 2007, under Section |
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402.084(c-3), the health care insurer may file not later than March |
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1, 2008: |
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(1) a subclaim with the division under Subsection (l) |
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if a request for reimbursement has been presented and denied by a |
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workers' compensation insurance carrier; or |
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(2) a request for reimbursement under Subsection (f) |
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if a request for reimbursement has not previously been presented |
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and denied by the workers' compensation insurance carrier. |
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SECTION 9. The change in law made by this Act applies to |
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workers' compensation medical disputes described by Section |
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413.031, Labor Code, as amended by this Act and Section 413.0311, |
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Labor Code, as added by this Act: |
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(1) that are pending for adjudication by the division |
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of workers' compensation of the Texas Department of Insurance on or |
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after the effective date of this Act; |
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(2) that may be remanded to the division of workers' |
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compensation of the Texas Department of Insurance on or after the |
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effective date of this Act; or |
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(3) that may arise on or after the effective date of |
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this Act. |
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SECTION 10. Chapter 408, Labor Code, as amended by this Act, |
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applies only to a claim for workers' compensation benefits based on |
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a compensable injury that occurs on or after the effective date of |
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this Act. A claim based on a compensable injury that occurs before |
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that date is governed by the law in effect on the date that the |
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compensable injury occurred, and the former law is continued in |
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effect for that purpose. |
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SECTION 11. The change in law made by this Act applies only |
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to a subclaim based on a compensable injury that occurred on or |
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after September 1, 2007, and to reimbursement requests and |
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subclaims pursuant to Section 409.0091(s), Labor Code, as added by |
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this Act. The changes made by this Act apply only to subclaims |
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based on an injury that has not been denied for compensability or |
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that has been determined by the division to be compensable. |
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SECTION 12. The commissioner of workers' compensation shall |
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prescribe any forms required under Section 409.0091, Labor Code, as |
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added by this Act, not later than September 1, 2007. |
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SECTION 13. The commissioner of workers' compensation and |
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the commissioner of insurance shall adopt rules as required by this |
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Act not later than December 1, 2007. |
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SECTION 14. This Act takes effect September 1, 2007. |
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______________________________ |
______________________________ |
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President of the Senate |
Speaker of the House |
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I certify that H.B. No. 724 was passed by the House on April |
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27, 2007, by the following vote: Yeas 135, Nays 0, 1 present, not |
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voting; and that the House concurred in Senate amendments to H.B. |
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No. 724 on May 23, 2007, by the following vote: Yeas 145, Nays 0, 1 |
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present, not voting. |
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______________________________ |
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Chief Clerk of the House |
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I certify that H.B. No. 724 was passed by the Senate, with |
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amendments, on May 18, 2007, by the following vote: Yeas 30, Nays |
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0. |
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______________________________ |
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Secretary of the Senate |
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APPROVED: __________________ |
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Date |
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__________________ |
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Governor |