413.008
(a) On request from the division for specific information, an insurance carrier shall provide to the division any information in the carrier’s possession, custody, or control that reasonably relates to the division’s duties under this subtitle and to health care: (1) treatment; (2) services; (3) fees; and (4) charges. (b) The division shall keep confidential […]
413.011
(a) The commissioner shall adopt health care reimbursement policies and guidelines that reflect the standardized reimbursement structures found in other health care delivery systems with minimal modifications to those reimbursement methodologies as necessary to meet occupational injury requirements. To achieve standardization, the commissioner shall adopt the most current reimbursement methodologies, models, and values or weights […]
413.0111
The rules adopted by the commissioner for the reimbursement of prescription medications and services must authorize pharmacies to use agents or assignees to process claims and act on the behalf of the pharmacies under terms and conditions agreed on by the pharmacies. Added by Acts 2005, 79th Leg., ch. 265, § 3.234, eff. Sept. 1, […]
413.013
The commissioner by rule shall establish: (1) a program for prospective, concurrent, and retrospective review and resolution of a dispute regarding health care treatments and services; (2) a program for the systematic monitoring of the necessity of treatments administered and fees charged and paid for medical treatments or services, including the authorization of prospective, concurrent, […]
413.0141
The commissioner may by rule provide that an insurance carrier shall provide for payment of specified pharmaceutical services sufficient for the first seven days following the date of injury if the health care provider requests and receives verification of insurance coverage and a verbal confirmation of an injury from the employer or from the insurance […]
413.015
(a) Insurance carriers shall make appropriate payment of charges for medical services provided under this subtitle. An insurance carrier may contract with a separate entity to forward payments for medical services. Any payment due the insurance carrier from the separate entity must be made in accordance with the contract. The separate entity is subject to […]
413.016
(a) The division shall order a refund of charges paid to a health care provider in excess of those allowed by the medical policies or fee guidelines. The division shall also refer the health care provider alleged to have violated this subtitle to the division of compliance and practices.1 (b) If the division determines that […]
413.017
The following medical services are presumed reasonable: (1) medical services consistent with the medical policies and fee guidelines adopted by the commissioner; and (2) medical services that are provided subject to prospective, concurrent, or retrospective review as required by the medical policies of the division and that are authorized by an insurance carrier. Acts 1993, […]
413.018
(a) The commissioner by rule shall provide for the periodic review of medical care provided in claims in which guidelines for expected or average return to work time frames are exceeded. (b) The division shall review the medical treatment provided in a claim that exceeds the guidelines and may take appropriate action to ensure that […]
413.020
The commissioner by rule shall establish procedures to enable the division to charge: (1) an insurance carrier a reasonable fee for access to or evaluation of health care treatment, fees, or charges under this subtitle; and (2) a health care provider who exceeds a fee or utilization guideline established under this subtitle or an insurance […]