DECISION AND ORDER

Behavioral Healthcare Associates (Provider) appealed the decision of the Texas Workers’ Compensation Commission’s Medical Review Division (MRD), which denied Provider’s claim that it was due $180.00, for one hour of psychological evaluation, from The University of Texas System (Carrier). The Administrative Law Judge (ALJ) concludes that Provider failed to met its burden of proving that the evaluation should be reimbursed.

I. JURISDICTION, NOTICE, AND VENUE

There were no contested issues of jurisdiction, notice or venue. Those issues are addressed in the Findings of Fact and Conclusions of Law without further discussion here.

II. STATEMENT OF THE CASE

Administrative Law Judge Tommy L. Broyles convened a hearing in this case on September 2, 2004, at the State Office of Administrative Hearings (SOAH), William Clements State Office Building, Austin, Texas. Carrier appeared through its attorney, Bradley D. McClellan. Provider appeared through Pamela Jones, an employee. Carrier called Ms. Jones to testify and both parties submitted medical records and bills, which were admitted into evidence. The record closed the same day.

III. DISCUSSION

Provider billed Carrier for six hours of psychological evaluation, including four hours for testing and two hours for an interview. Carrier paid for all four hours of the testing and one hour for the interview, declining to reimburse the remaining hour as not medically necessary. Provider argued that it provided the service as indicated on the bill and should be reimbursed. Carrier argued that a two hour interview was not medically necessary; that Ms. Jones testimony established that the doctor who provided the services did not complete the billing; and that the date of service is not supported by the medical records. Ms. Jones responded that only the last date of service was reported in order to avoid confusion and that the billing from a different doctor than the one who performed the services resulted from simple human error.

Having considered the evidence in this case, the ALJ finds that the additional hour of psychological evaluation was not adequately documented by Provider and should not be reimbursed by Carrier. Provider indicated that a different doctor billed for the services in question, leading Carrier to reasonably believe this was a peer-review evaluation and was not medically necessary. Further, Provider failed to prove that two hours, regardless of who conducted the interview, was necessary. Consequently, the ALJ does not order reimbursement for the services at issue.

IV. FINDINGS OF FACT

1. Provider provided six hours psychotherapy evaluation to Claimant, including four hours of testing and two hours of interviews.
2. Carrier reimbursed Provider for all four hours of testing and one hour of the interview.
3. Carrier declined to reimburse Provider for one hour of the interview based on its claim that Provider had failed to show it was medically necessary.
4. Provider filed a timely Request for Medical Dispute Resolution.
5. On January 5, 2004, the MRD issued its Findings and Decision, ruling that Provider was not entitled to reimbursement.
6. Provider filed a timely request for a hearing before SOAH.
7. Notice of the hearing was sent to all parties on May 4, 2004.
8. The notice contained a statement of the time, place, and nature of the hearing; a statement of the legal authority and jurisdiction under which the hearing was to be held; a reference to the particular sections of the statutes and rules involved; and a short, plain statement of the matters asserted.
9. The hearing was held September 2, 2004. Provider and Carrier participated in the hearing, which was adjourned the same day.
10. Provider incorrectly indicated in its billing that a doctor, other than the one who performed the services, was billing Carrier for the work performed.
11. Provider failed to prove that a two-hour interview was medically necessary.

V. CONCLUSIONS OF LAW

1. SOAH has jurisdiction over this proceeding, including the authority to issue a decision and order, pursuant to Tex. Lab. Code Ann. ‘ 413.031 and Tex. Gov’t Code Ann. ch. 2003.
2. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. ‘ 2001.052.
3. Provider, as the petitioner, has the burden of proof in this matter. 28 Tex. Admin. Code ‘ 148.21(h).
4. Provider failed to prove that a two-hour interview was medically necessary health care under

Tex. Lab. Code Ann. ‘ 401.011 and 408.021(a).

1. Carrier should not reimburse Provider for the one hour of interview in dispute.

ORDER

The University of Texas System is not required to reimburse Behavioral Healthcare Associates for the additional hour of psychological evaluation.

Signed October 18, 2004.

TOMMY L. BROYLES
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS