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At a Glance:
Title:
08059-m4r
Date:
May 12, 2008

08059-m4r

May 12, 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 benefit contested case hearing was opened on January 7, 2008, and closed on May 12, 2008, to decide the following disputed issue:

  1. Whether (health care provider) is not entitled to reimbursement of $37.44 plus interest for services rendered to Claimant on October 6, 2005?

PARTIES PRESENT

Carrier appeared and was represented by attorneys, PP and KP. Respondent/Subclaimant did not appear and did not respond to a 10-day letter.

BACKGROUND

The Respondent/Subclaimant did not appear for the Contested Case Hearing scheduled for March 10, 2008. A letter was sent to the Respondent/Subclaimant on March 12, 2008, offering it an opportunity to request that the hearing be reset to permit it to present evidence on the disputed issue. Respondent/Subclaimant did not respond to the letter.

The original billing for the services perform by Respondent/Subclaimant was in regard to an epidural steroid injection with flouroscopy guidance. The original charges for services on October 6, 2005, were submitted to the Carrier in the amounts of $108.41 under CPT Code 62311 and $38.38 under CPT Code 76005. The maximum allowable reimbursement for the latter in (County 1), Texas, is $37.44. CPT Code 62311 is for the injection; and CPT Code 76005 is for flouroscopic guidance. The charge was properly denied by Carrier in that flouroscopy is an inclusive component of CPT Code 62311 when performed in the same operative session.

Therefore, Carrier has met its burden of proof that (health care provider) is not entitled to reimbursement of $37.44 plus interest for services rendered to Claimant on October 6, 2005.

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 Commission sent a single document stating the true corporate name of the Carrier and name and street address of Carrier’s registered agent with the 10-day letter to the Respondent/Subclaimant and Claimant at their addresses of record. That document was admitted into evidence as Hearing Officer Exhibit Number 2.
  2. On ____, the Claimant lived within seventy-five miles of the (City) Field Office.
  3. On ____, the Claimant was an employee of (employer).
  4. On ____, the Employer was a subscriber to workers’ compensation when Claimant sustained a compensable injury.
  5. The Respondent/Subclaimant failed to appear for the March 10, 2008 Contested Case Hearing and failed to respond to the 10-day letter.
  6. No evidence was received that showed that the Respondent/Subclaimant had good cause for its failure to appear for the Contested Case Hearing.
  7. The charge of $38.28 or the maximum allowable reimbursement of $37.44 plus interest for services rendered to Claimant on October 6, 2005, under CPT Code 76005, was for a service included under CPT Code 62311 for which Carrier paid Respondent/Subclaimant.

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 $37.44 plus interest for services rendered to Claimant on October 6, 2005.
  4. Respondent/Subclaimant did not have good cause for its failure to appear for the Contested Case Hearing.

DECISION

(Health care provider) is not entitled to reimbursement of $37.44 plus interest for services rendered to Claimant on October 6, 2005. Respondent/Subclaimant did not have good cause for its failure to appear for the Contested Case Hearing.

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 MITSUI SUMITOMO INSURANCE COMPANY OF AMERICA and the name and address of its registered agent for service of process is

PRENTICE-HALL CORPORATION SYSTEM, INC.

800 BRAZOS

AUSTIN, TEXAS 78701

Signed this 12th day of May, 2008.

Charles T. Cole
Hearing Officer

End of Document
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