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At a Glance:
Title:
08053
Date:
April 18, 2008
Status:
Medical Fees

08053

April 18, 2008

DECISION AND ORDER

This case is decided pursuant to Chapter 410 of the Texas Workers’ Compensation Act and Rules of the Division of Workers’ Compensation adopted thereunder.

ISSUE

A contested case hearing was held on 04/09/08 to decide the following disputed issue:

  1. Whether the preponderance of the evidence is contrary to the Medical

Fee Dispute Resolution Findings and Decision that (health care provider)

Assoc. has forfeited the right to reimbursement of $1,793.13, for

services rendered between (date of injury) and 06/25/07, because the bill was

not timely filed.

PARTIES PRESENT

Carrier appeared and was represented by an (Attorney). Provider appeared and was represented RD and LV, lay representives. (Claimant) did not appear, and his attendance was waived.

BACKGROUND INFORMATION

The Parties stipulated that (Claimant) was injured in the course and scope of his employment on (date of injury). It is not disputed that (health care provider) provided health care services to (Claimant) between (date of injury) and 06/25/07. Texas Labor Code 480.027 requires the providers to send their bill to the Carrier within 95 days from the date of service. Failure to timely submit a claim for payment to the Carrier, constitutes a forfeiture of the right to reimbursement.

In this case, (health care provider) should have sent their bill to the Carrier by 09/25/07. Evidence establishes the Carrier received the bill on 10/31/07, well outside the 95 days. (health care provider) argued that they had timely, and in good faith, sent their bill to their "clearing-house", THIN. There is no evidence that THIN sent the bill to the Carrier before 10/31/07.

The preponderance of the evidence reflects that (health care provider) did not timely submit their bill to the Carrier, and has forfeited the right to reimbursement.

Even though all the evidence presented was not discussed, it was considered. The Findings of Fact and Conclusions of Law are based on all of the evidence presented.

FINDINGS OF FACT

  1. The Parties stipulated to the following facts:

A.Venue is proper in the (City) Field Office of the Texas Department of Insurance, Division of Workers’ Compensation.

B.On (date of injury), Claimant was the employee of Employer.

C.Claimant was injured in the course and scope of his employment on (date of injury).

  • Carrier delivered to Claimant a single document stating the true corporate name of Carrier, and the name and street address of Carrier’s registered agent, which document was admitted into evidence as Hearing Officer’s Exhibit Number 2.
  • (Health care provider) provided health care services to (Claimant) on (date of injury) through 06/25/07.
  • (Health care provider) did not send their bill to the Carrier within 95 days of providing the services.
  • CONCLUSIONS OF LAW

    1. The Texas Department of Insurance, Division of Workers’ Compensation, has jurisdiction to hear this case.
    2. Venue is proper in the (City) Field Office.
    3. The preponderance of the evidence is not contrary to the Medical Fee Dispute Resolution Findings and Decision that (health care provider) has forfeited the right to reimbursement of $1,793.13 for dates of service between (date of injury) and 06/25/07.

    DECISION

    The preponderance of the evidence is not contrary to the Medical Fee Dispute Resolution

    Findings and Decision that (health care provider) has forfeited the right to reimbursement of

    $1,793.13 for dates of service between (date of injury) and 06/25/07.

    ORDER

    Carrier is not liable for the benefits at issue in this Hearing. Claimant remains entitled to medical benefits for the compensable injury in accordance with §408.021.

    The true corporate name of the insurance carrier is TRAVELERS INDEMNITY COMPANY and the name and address of its registered agent for service of process is:

    CORPORATION SERVICE COMPANY

    D/B/A/ CSC--LAWYERS INCORPORATING SERVICE COMPANY

    701 BRAZOS STREET #1050

    AUSTIN, TEXAS 78701

    Signed this 18th day of April 2008.

    G. W. Quick
    Hearing Officer

    End of Document
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