Texas Labor Code

§ 413.031 — MEDICAL DISPUTE RESOLUTION

LA § 413.031Title 5. WORKERS' COMPENSATION · Part A. TEXAS WORKERS' COMPENSATION ACT · Ch. 413. MEDICAL REVIEW · Art. C. DISPUTE RESOLUTION

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(a)A party, including a health care provider, is entitled to a review of a medical service provided or for which authorization of payment is sought if a health care provider is:

(1)denied payment or paid a reduced amount for the medical service rendered;

(2)denied authorization for the payment for the service requested or performed if authorization is required or allowed by this subtitle or commissioner rules;

(3)ordered by the commissioner to refund a payment received; or

(4)ordered to make a payment that was refused or reduced for a medical service rendered.

(b)A health care provider who submits a charge in excess of the fee guidelines or treatment policies is entitled to a review of the medical service to determine if reasonable medical justification exists for the deviation. A claimant is entitled to a review of a medical service for which preauthorization is sought by the health care provider and denied by the insurance carrier. The commissioner shall adopt rules to notify claimants of their rights under this subsection.

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Legislative history

Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 3.245, eff. September 1, 2005. Acts 2007, 80th Leg., R.S., Ch. 133 (H.B. 1003), Sec. 2, eff. September 1, 2007. Acts 2007, 80th Leg., R.S., Ch. 1007 (H.B. 724), Sec. 1, eff. September 1, 2007. Acts 2007, 80th Leg., R.S., Ch. 1218 (H.B. 2004), Sec. 6, eff. September 1, 2007. Acts 2009, 81st Leg., R.S., Ch. 1330 (H.B. 4290), Sec. 18, eff. September 1, 2009. Acts 2011, 82nd Leg., R.S., Ch. 1066 (S.B. 809), Sec. 2, eff. September 1, 2011. Acts 2011, 82nd Leg., R.S., Ch. 1162 (H.B. 2605), Sec. 18, eff. September 1, 2011. Acts 2011, 82nd Leg., R.S., Ch. 1162 (H.B. 2605), Sec. 37(1), eff. September 1, 2011. Acts 2019, 86th Leg., R.S., Ch. 1218 (S.B. 1742), Sec. 3.14, eff. September 1, 2019.