454-13-1462-m4
DECISION AND ORDER ON SUMMARY DISPOSITION This case involves a fee dispute for services rendered by Vista Medical Center Hospital (Provider) to an injured worker (Claimant). Provider seeks additional reimbursement from Commerce & Industry Insurance Company (Carrier) for services rendered to Claimant. Carrier filed a motion for summary disposition in this case, arguing that Claimant […]
454-15-1586-m4-np
DECISION AND ORDER ____, a self-insured party, appeals the approval of reimbursement to Texas Health Huguley (Provider) for services provided to an injured worker because the Provider failed to obtain required preauthorization. The Administrative Law Judge (ALJ) concludes that Provider was not required to obtain preauthorization. Consequently, Provider is entitled to reimbursement. I.I. PROCEDURAL HISTORY, […]
454-15-1565-m4-np
DECISION AND ORDER _______ seeks reimbursement from Arch Insurance Company (Carrier) for medical costs she allegedly incurred after being injured at work. Over two years after her injury occurred, she sought a medical fee dispute resolution (MFDR) from the Texas Department of Insurance, Division of Workers’ Compensation (Division). The Division’s Medical Fee Dispute Resolution Findings […]
454-14-4080-m4-np
REVISED DECISION AND ORDER Dallas Independent School District (Carrier) 1 challenges the order of reimbursement to Texas Health Presbyterian Hospital of Dallas (Provider) for inpatient services provided to an injured worker (Claimant). The Administrative Law Judge (ALJ) concludes that Carrier met its burden of proof to show that the order incorrectly calculated the reimbursement amount, […]
454-14-4081-m4-np
DECISION AND ORDER New Hampshire Insurance Company (Carrier) challenges the order granting additional reimbursement to Texas Health of Azle (Provider) for services provided to an injured worker in an emergency room. The issue in this case is whether the Provider is entitled to additional reimbursement for services billed under Current Procedural Terminology Code (CPT) 96375. […]
454-14-2499-m4
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 […]
454-11-5700-m4
DECISION AND ORDER I. INTRODUCTION This docket consolidated for hearing 23 cases (Consolidated Docket), listed on Attachment A, because they involve the same basic legal issues and evidence. Each case involves hospital outpatient services rendered by Vista Medical Center Hospital, Vista Hospital of Dallas, or Surgery Specialty Hospital of America (collectively “Vista”) between 2003 and […]
454-14-1702-m4
DECISION AND ORDER I. INTRODUCTION This case involves clinical laboratory services rendered by Texas Medical Toxicology (TMT) to an injured employee covered by the workers’ compensation insurance system. The Texas Department of Insurance’s Division of Workers’ Compensation (Division)[1] conducted medical dispute resolution (MDR) and ordered Texas Mutual Insurance Company (Carrier) to make an additional reimbursement […]
454-11-2417-m4-etal
DECISION AND ORDER I. INTRODUCTION This docket consolidated for hearing 113 cases (listed on Attachments A and B) because they involve the same basic legal issues and evidence (Consolidated Docket). Each case involves hospital outpatient services rendered by Renaissance Hospitals (Renaissance)[1] between 2002 and 2007 to an injured employee covered by the Texas workers’ compensation […]
454-14-1561-m4-np
DECISION AND ORDER St. David’s Rehabilitation Oaks Hospital (Provider) requested a hearing to contest a medical fee dispute resolution order issued by the Texas Department of Insurance, Division of Workers’ Compensation (Division) regarding a claim for $52,490.00 in medical services provided to ___ (Claimant). In its order, the Division found that Provider was not entitled […]