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A BILL TO BE ENTITLED
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AN ACT
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relating to resolution of certain disputes regarding workers' |
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compensation claims for medical 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 dispute involving health care provider fees that |
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do not exceed $2,000; and |
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(2) appeal of an independent review organization |
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decision regarding determination of the medical necessity of a |
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health care service, the cost for which does not exceed $3,000. |
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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. The change in law made by this Act applies to a |
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workers' compensation medical dispute described by Section |
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413.031, Labor Code, as amended by this Act: |
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(1) that is pending for an adjudication by the |
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division of workers' compensation of the Texas Department of |
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Insurance on or after the effective date of this Act; or |
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(2) that arises on or after the effective date of this |
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Act. |
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SECTION 4. This Act takes effect September 1, 2007. |