DECISION AND ORDER

Plaza Specialty Hospital (Plaza) seeks additional reimbursement from Highlands Casualty Company (Highlands) for inpatient hospital services it provided to a workers’ compensation claimant from August 20, 2008, to September 26, 2008. Plaza failed to prove it was entitled to additional reimbursement. Accordingly, its request for additional reimbursement is denied.

I.JURISDICTION, NOTICE, AND PROCEDURAL HISTORY

There are no issues of notice or jurisdiction. Therefore, these matters are addressed in the Findings of Fact and Conclusions of Law without further discussion.

Plaza filed a request for medical fee dispute resolution with the Medical Review Division (MRD) of the Texas Department of Insurance, Division of Workers’ Compensation (Division). The Division’s Medical Fee Dispute Resolution Findings and Decision (MRD Decision) denied Plaza additional reimbursement. Plaza timely requested a hearing before the State Office of Administrative Hearings (SOAH) to contest the MRD Decision. A hearing convened before Administrative Law Judge Gary Elkins on July 9, 2014, at SOAH’s facilities in Austin, Texas. Plaza was represented by attorney P. Matthew O’Neil. Highlands was represented by attorney James M. Loughlin. The record closed on August 1, 2014, following the filing of post-hearing briefs.

I.DECISION

The claimant was admitted to Plaza’s facility on August 20, 2008, and discharged on September 26, 2008, for a total length of stay of 37 days. Plaza obtained and was granted preauthorization for dates of service August 20-25, 2008. It neither requested nor was given preauthorization for services provided beyond August 25, 2008. It also failed to prove it was entitled to reimbursement for the preauthorized dates at an amount greater than the reimbursement paid by Highlands. Consequently, as set out in the Findings of Fact and Conclusions of Law, it is not entitled to additional reimbursement.

FINDINGS OF FACT

1. Plaza Specialty Hospital (Plaza) seeks additional reimbursement from Highlands Casualty Company (Highlands) for inpatient hospital services it provided to a workers’ compensation claimant from August 20, 2008, to September 26, 2008.
2. Plaza obtained preauthorization from Highlands for dates of service August 20, 2008, to August 25, 2008, but did not obtain preauthorization for dates of service August 26, 2008, to September 26, 2008.
3. After Highlands reimbursed Plaza $9,318.39 for services provided on the preauthorized days, Plaza requested additional reimbursement, which Highlands denied.
4. Plaza timely requested medical fee dispute resolution with the Texas Department of Insurance, Division of Workers’ Compensation (Division).
5. On February 14, 2014, the Division’s Medical Review Division issued its Medical Fee Dispute Resolution Findings and Decision (MRD Decision), which found that no additional reimbursement was owed to Plaza.
6. Plaza timely requested a hearing before the State Office of Administrative Hearings (SOAH) to contest the MRD Decision.
7. A Notice of Hearing informed the parties of the date, time, and location of the hearing; the matters to be considered; the legal authority under which the hearing would be held; and the statutory provisions applicable to the matters to be considered.
8. A hearing convened before Administrative Law Judge Gary Elkins on July 9, 2014, at SOAH’s facilities in Austin, Texas. Plaza was represented by attorney P. Matthew O’Neil. Highlands was represented by attorney James M. Loughlin. The record closed on August 1, 2014, following the filing of post-hearing briefs.
9. Plaza did not to prove it is entitled to more than $9,318.39 for the services rendered.

II.CONCLUSIONS OF LAW

1. SOAH has jurisdiction over this proceeding, including the authority to issue a decision and order, pursuant to Texas Labor Code § 413.031 and Texas Government Code ch. 2003.
2. Adequate and timely notice of the hearing was provided in accordance with Texas Government Code §§ 2001.051 and 2001.052.
3. Plaza was required to obtain preauthorization for the claimant’s inpatient hospital admission. 28 Texas Administrative Code § 134.600(p)(1).
4. The services provided to the claimant were not covered by a fee guideline adopted by the Division, so they were required to be billed and reimbursed at a fair and reasonable rate, within the meaning of Texas Labor Code § 413.011.
5. Plaza failed to prove the reimbursement it requested was fair and reasonable.
6. Plaza is not entitled to additional reimbursement from Highlands for the services provided to the claimant from August 26, 2008, to September 26, 2008.
7. ORDER

IT IS ORDERED thatPlaza is not entitled to additional reimbursement for the services provided to the claimant.

Signed September 25, 2014.