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A BILL TO BE ENTITLED
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AN ACT
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relating to workers' compensation subclaims. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. 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 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) 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 provide the requested information not later than the |
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30th day after the date the workers' compensation insurance carrier |
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requests the information. The workers' compensation insurance |
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carrier and the health care insurer may establish additional |
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periods for compliance with this subsection by written mutual |
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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 with the division, |
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but not later than March 1, 2008: |
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(1) a subclaim under Subsection (l) if a request for |
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reimbursement has been presented and denied by a workers' |
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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 3. 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 4. 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 5. 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 6. This Act takes effect September 1, 2007. |