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At a Glance:
Title:
08063
Date:
May 20, 2008
Status:
Medical Fees

08063

May 20, 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 April 28, 2008, and closed on May 20, 2008, to decide the following disputed issue:

  1. Whether Carrier is liable to (Provider), in the amount of $288.68 for additional services rendered to the Claimant on March 29, 2007?

PARTIES PRESENT

Carrier appeared and was represented by attorney CL. 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 April 28, 2008. A letter was sent to the Respondent/Subclaimant on April 28, 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.

On April 20, 2007, Carrier received a bill from the Respondent/Subclaimant in the amount of $16.58 for CPT Code 97035 for services rendered on March 29, 2007. Carrier paid the bill.

It was not until January 18, 2008 that Carrier received a bill marked "REQUEST FOR RECONSIDERATION" for additional charges by Respondent/Subclaimant for services rendered on March 29, 2008, which charges totaled $337.67. Although marked as a reconsideration request, the documents received by Carrier on January 18, 2008, had never been submitted to Carrier previously. On April 4, 2008, the Medical Fee Dispute Resolution Findings and Decision was issued ordering Carrier to pay the additional amount of $288.68 plus interest for the additional services billed for March 29, 2007.

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 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) when he sustained a compensable injury.
  4. On ____, the Employer was a subscriber to workers’ compensation.
  5. The Respondent/Subclaimant failed to appear for the April 28, 2008 Contested Case Hearing and failed to respond to the 10-day letter.
  6. The health care provider did not submit a proper bill to carrier in the amount of $337.67 for additional services provided to Claimant on March 29, 2007, until after the 95th day after the date on which the health care services were provided to Claimant.
  7. Carrier properly denied the $337.67 for additional services provided to Claimant on March 29, 2007.
  8. On April 4, 2008, the Medical Fee Dispute Resolution Findings and Decision was issued ordering Carrier to pay the additional amount of $288.68 plus interest for the additional services billed for March 29, 2007.
  9. No evidence was received that showed that the Requestor/Subclaimant had good cause for his failure to appear for the Contested Case Hearing.

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. Carrier is not liable to (Provider), for the additional amount of $288.68 plus interest for the additional services billed for March 29, 2007.
  4. Respondent/Subclaimant did not have good cause for its failure to appear for the Contested Case Hearing.

DECISION

Carrier is not liable to (Provider), for the additional amount of $288.68 plus interest for the additional services billed for March 29, 2007. Respondent/Subclaimant did not have good cause for his 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 TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA and the name and address of its registered agent for service of process is

CORPORATION SERVICE COMPANY

DBA CSC - LAWYERS INCORPORATING SERVICE COMPANY

701 BRAZOS STREET, SUITE 1050

AUSTIN, TEXAS 78701

Signed this 20th day of May, 2008.

Charles T. Cole
Hearing Officer

End of Document
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