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A BILL TO BE ENTITLED
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AN ACT
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relating to reimbursement procedures and to the resolution of |
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certain medical disputes regarding workers' compensation claims. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Subsection (d), Section 408.027, Labor Code, is |
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amended to 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 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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carrier denies compensability, and the injury is later determined |
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to be compensable, the accident or health insurance carrier or |
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other person may recover the amounts paid for such services from the |
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workers' compensation insurance carrier. If an accident or health |
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insurance carrier or other person obligated for the cost of health |
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care services has paid for health care services for an employee for |
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an injury for which a workers' compensation carrier or employer |
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accepts compensability, the accident or health insurance carrier or |
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other person may recover reimbursement from the insurance carrier |
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as described in Sections 409.009 and 409.0091. |
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SECTION 2. 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) This section applies only to a request for |
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reimbursement by a health care insurer or authorized representative |
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of a health care insurer. For purposes of this section, "health |
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care insurer" refers to an insurance carrier or an authorized |
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representative of an insurance carrier described by Section |
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402.084(c-1). |
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(b) Health care paid by a health care insurer is |
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reimbursable as a medical benefit. For purposes of this section, " |
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medical benefit" has the meaning assigned by Section 401.011(31). |
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(c) A request for reimbursement or subclaim of the health |
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care insurer is subject to the defense that the health care paid for |
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was not a medical benefit. |
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(d) 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) neither the subclaimant nor the health care |
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provider obtained preauthorization under Section 413.014 or rules |
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adopted under that section; |
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(3) the health care provider did not bill the |
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insurance carrier, as provided by Section 408.027, by the 95th day |
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after the date the health care paid for by the subclaimant was |
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provided; or |
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(4) the health care provider did not comply with this |
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subtitle or rules adopted under this subtitle. |
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(e) Subject to the time limits in Subsection (k), the health |
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care insurer shall provide with any reimbursement request the |
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following information to the insurance carrier: |
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(1) information identifying the workers' compensation |
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case, including the division case number, patient/claimant name, |
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patient/claimant social security number, and date of injury; and |
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(2) information describing the health care paid, |
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including provider name, provider tax identification number, date |
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of service, place of service, ICD-9 code, CPT code, amount charged |
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by the provider, and the amount paid by the health care insurer. |
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(f) The insurance carrier shall reduce the amount of the |
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reimbursable subclaim by any payments the insurance carrier had |
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previously made to the same health care provider for the provision |
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of the same health care on the same dates of service. When making |
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such a reduction in reimbursement to the subclaimant, the insurance |
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carrier shall provide appropriate documentation of the previous |
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payments. |
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(g) For each medical benefit paid, the insurance carrier |
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shall pay to the health care insurer the lesser of the amount |
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payable under the applicable fee guideline on the date of service or |
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the actual amount paid by the health care insurer. In the absence |
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of fee guidelines for a specific service paid, the amount paid by |
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the health care insurer shall be construed as a fair and reasonable |
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payment under Section 413.011(d). The health care insurer may not |
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recover interest as a part of the subclaim. |
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(h) Upon receipt of a request for reimbursement under this |
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section, the insurance carrier shall respond to the request in |
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writing within 90 days. If the insurance carrier refuses, fails to |
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pay, or reduces a request for reimbursement under this section, the |
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health care insurer may file a written claim with the division as a |
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subclaimant not later than 120 days from the date of receipt of the |
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carrier's notice of refusal, failure to pay, or reduction in |
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reimbursement. |
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(i) A subclaimant may request dispute resolution to address |
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the insurance carrier's refusal or denial of reimbursement. The |
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subclaimant must select one of the following options for dispute |
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resolution: |
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(1) the subclaimant may file a dispute in accordance |
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with Chapter 410; in a dispute under Chapter 410 that arises from a |
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subclaim under this section or Section 408.027(d), health care |
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benefits provided by a health care insurer are considered accrued |
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medical benefits provided to the claimant for purposes of Section |
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410.168(a)(3) and a hearing officer may award the health care |
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insurer, as a subclaimant, all or part of the subclaim and may order |
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the insurance carrier to pay the subclaim as part of a dispute |
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adjudication process under Chapter 410; or |
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(2) the subclaimant may request dispute resolution |
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under Section 413.0311; the commissioner and the commissioner of |
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insurance shall adopt rules to specify the appropriate dispute |
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resolution process for subclaimant disputes under Section |
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413.0311. |
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(j) For a reduction in payment, a subclaimant may request |
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medical dispute resolution to address the reduction in |
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reimbursement under Chapter 413. The commissioner and the |
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commissioner of insurance shall adopt rules to specify the |
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appropriate dispute resolution process for subclaimant disputes |
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under this subsection. |
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(k) Until December 31, 2008, a health care insurer must file |
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a request for reimbursement with the insurance carrier not later |
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than one year from the date that the health care insurer received |
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information under Section 402.084(c-3). Effective January 1, 2009, |
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a health care insurer must file a request for reimbursement with the |
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insurance carrier not later than six months from the date the health |
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care insurer received information under Section 402.084(c-3). |
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Effective January 1, 2009, a health care insurer must file a request |
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for reimbursement for a health care claim not later than the second |
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anniversary of the date the claim was paid. |
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SECTION 3. 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), that remains unresolved after a |
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review of the medical service under this section is entitled to a |
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hearing. A hearing under this subsection shall be conducted by the |
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State Office of Administrative Hearings not later than the 60th day |
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after the date on which the party notifies the division of the |
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request for a hearing. The hearing shall be conducted in the manner |
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provided for 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 4. 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. INDEPENDENT REVIEW ORGANIZATION DISPUTE |
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RESOLUTION FOR HEALTH CARE INSURER SUBCLAIMANTS. (a) This section |
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applies to subclaimant disputes regarding reimbursements under |
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Section 409.009 or 409.0091. If an insurance carrier refuses or |
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denies reimbursement, the subclaimant may request dispute |
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resolution from an independent review organization. Each |
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independent review organization performing independent review must |
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be certified under Chapter 4202, Insurance Code. |
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(b) Upon receipt of a denial or refusal for reimbursement, |
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the subclaimant has the rights of discovery of an insurance carrier |
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records or health care provider records that are available to the |
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parties in a contested case hearing. |
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(c) The subclaimant shall request dispute resolution and |
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present its written arguments and documentation supporting the |
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determination that the paid health care services were medical |
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benefits as defined under Section 401.011(31) to both the |
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independent review organization and the insurance carrier. |
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(d) The insurance carrier shall make a written response to |
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the independent review organization, with a copy provided to the |
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subclaimant within 20 business days. |
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(e) The independent review organization shall review the |
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facts and the parties' arguments and apply evidence-based medicine |
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and generally accepted standards of medical care recognized in the |
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medical community to determine whether the paid health care service |
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constitutes a medical benefit. The independent review organization |
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shall notify the parties of its determination within 60 days of |
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receipt of the initial subclaimant request for dispute resolution. |
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(f) If the independent review organization determines that |
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a service is a medical benefit, the insurance carrier shall |
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reimburse the subclaimant in the appropriate amount within 15 |
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business days. |
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(g) The independent review organization review fee shall be |
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paid by the subclaimant at the time of its request for dispute |
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resolution. If the subclaimant prevails, in whole or in part in the |
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dispute, the entire fee shall be reimbursed to the subclaimant by |
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the insurance carrier together with the required medical benefit |
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reimbursement under Subsection (f). |
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SECTION 5. (a) Except as provided by Subsection (b) of |
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this section, 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 a hearing by the division of |
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workers' compensation of the Texas Department of Insurance on the |
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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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(b) A court in which judicial review of a workers' |
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compensation medical dispute described by Section 413.031, Labor |
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Code, as amended by this Act, is pending on the effective date of |
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this Act shall dismiss the case to permit the party bringing the |
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action to obtain a hearing in the manner described by Subsection |
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(k), Section 413.031, Labor Code, as amended by this Act. A |
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dismissal under this subsection is without prejudice to the ability |
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of the party to bring a new action under Subsection (k-1), Section |
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413.031, Labor Code, as added by this Act. |
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SECTION 6. The change in law made by this Act applies only |
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to a subclaim based on a compensable injury occurring on or after |
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September 1, 2007. A subclaim based on a compensable injury |
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occurring before that date is governed by the law in effect on the |
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date the injury occurred, and the former law is continued in effect |
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for that purpose. Except as otherwise provided by this Act, rules |
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required to be adopted by the change in law made by this Act shall be |
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adopted not later than December 31, 2007. |
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SECTION 7. Any forms required under Section 409.0091, Labor |
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Code, as added by this Act, shall be prescribed by the commissioner |
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of workers' compensation not later than 60 days after the effective |
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date of this Act. |
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SECTION 8. This Act takes effect September 1, 2007. |