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At a Glance:
Title:
08058
Date:
May 9, 2008
Status:
Medical Fees

08058

May 9, 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 May 1, 2008, to decide the following disputed issue:

  1. Whether (health care provider) is entitled to reimbursement of $68.25 for services rendered to Claimant on June 21, 2007?

PARTIES PRESENT

Petitioner/Subclaimant appeared and was represented by SK and MG, laypersons. Carrier appeared and was represented by MS, attorney.

BACKGROUND INFORMATION

The health care provider billed the Carrier the sum of $68.25 for services rendered on June 21, 2006. Although submitted within 95 days after the date of service, the first bill submitted to the Carrier was incorrectly coded. On or about January 1, 2007, the health care provided submitted a corrected bill which was properly coded. Carrier then denied the bill. A Medical Fee Dispute Resolution Findings and Decision was issued on March 17, 2008, finding that the request was not timely filed and that the health care provider has forfeited the right to reimbursement.

Section 408.027(a) of the Texas Workers' Compensation Act provides,

"A health care provider shall submit a claim for payment to the insurance carrier not later than the 95th day after the date on which the health care services are provided to the injured employee. Failure by the health care provider to timely submit a claim for payment constitutes a forfeiture of the provider's right to reimbursement for that claim for payment."

There is no provision under the Act or Rules allowing resubmission of an improperly submitted bill after the time period provided for in Section 408.027(a). Because the bill was not properly submitted before the expiration of the 95 day period, the health care provider forfeited the right to reimbursement for that claim for payment.

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 ___, Claimant was the employee of (employer), when he sustained a compensable injury.

  • Carrier delivered to the health care provider 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.
  • The health care provider did not submit a proper bill to carrier in the amount of $68.25 for services provided Claimant on June 21, 2007, until after the 95th day after the date on which the health care services were provided to Claimant.
  • 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. (Health care provider) is not entitled to reimbursement of $68.25 for services rendered to Claimant on June 21, 2007.

    DECISION

    (Health care provider) is not entitled to reimbursement of $68.25 for services rendered to Claimant on June 21, 2007.

    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 TEXAS MUTUAL INSURANCE COMPANY and the name and address of its registered agent for service of process is

    MR. RUSSELL OLIVER, PRESIDENT

    TEXAS MUTUAL INSURANCE COMPANY

    6210 EAST HIGHWAY 290

    AUSTIN, TEXAS 78723

    Signed this 9th day of May, 2008.

    Charles T. Cole
    Hearing Officer

    End of Document
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