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At a Glance:
Title:
08091
Date:
July 1, 2008
Status:
Medical Fees

08091

July 1, 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.

ISSUES

A benefit contested case hearing was held on June 26, 2008 to decide the following disputed issue:

Is the Respondent entitled to reimbursement in the amount of $10 plus applicable accrued interest under CPT Code 97546-WH for services rendered on August 7, 2007?

Upon agreement of the parties, the following issue was added:

Is Petitioner/Carrier in compliance with the Medical Fee Dispute Resolution Findings and Decision in which it was determined that Requester/Respondent is entitled to $102.40 plus applicable interest related to services rendered on August 7, 2007?

PARTIES PRESENT

Petitioner was represented by Ms. CK, attorney at law. Respondent was represented by Ms. S D, Respondent’s Claim Representative.

BACKGROUND INFORMATION

It was undisputed that Respondent, DP, D.C., provided services, CPT Code 97546-WH, to Claimant on August 7, 2007. Payment of the subject fees was initially denied by Petitioner, SUA Insurance Company. As such, Respondent filed a Request for Medical Dispute Resolution (DWC Form 60). Prior to any action having been taken by Medical Review, Petitioner issued a Notice of Resolution letter indicating Petitioner agreed to pay $102.40 plus interest for services rendered by Respondent on August 7, 2007. Petitioner tendered said payment and the same was received by Respondent; and the parties requested withdrawal of the dispute and that no further action be taken by Medical Review. Despite the parties’ resolution of the matter, a Medical Fee Dispute Resolution Findings and Decision was issued holding Petitioner liable for the subject fees. Petitioner appealed, and the parties have elected to pursue this matter at a contested case hearing, to ensure clarification that payment of the subject fees is not outstanding and Petitioner is in compliance with the Medical Fee Dispute Resolution Findings and Decision. Petitioner, without objection from Respondent, has requested that the hearing officer’s Decision and Order include a specific finding of fact regarding payment by Petitioner and a conclusion of law that Petitioner is in compliance.

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. Venue is proper in the (City) Field Office of the Texas Department of Insurance, Division of Workers’ Compensation.
  2. On ___________, Claimant was the employee of (Employer).
  3. On ___________, the employer had workers' compensation insurance coverage with SUA Insurance Company.
  4. On August 7, 2007, Respondent provided services, CPT Code 97546-WH, to Claimant; and Respondent requested reimbursement from Petitioner for such services.
  5. Petitioner initially denied payment for the services, CPT Code 97546-WH, provided by Respondent to Claimant on August 7, 2007.
  6. On February 14, 2008, Respondent filed a Medical Fee Dispute Resolution Request (DWC Form 60).
  7. Prior to the issuance of the Medical Fee Dispute Resolution Findings and Decision, Petitioner tendered payment to Respondent for the subject fees of $102.40 plus interest for services rendered by Respondent on August 7, 2007 under CPT Code 97546-WH.
  8. Consistent with the Medical Fee Dispute Resolution Findings and Decision, Petitioner has made payment of $102.40 plus interest for services rendered by Respondent on August 7, 2007 under CPT Code 97546-WH.

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. Respondent is entitled to reimbursement in the amount of $102.40 plus applicable accrued interest under CPT Code 97546-WH for services rendered on August 7, 2007.
  4. Petitioner has tendered to Respondent payment in the amount of $102.40 plus applicable accrued interest under CPT Code 97546-WH for services rendered on August 7, 2007, Petitioner is in compliance with the Medical Fee Dispute Resolution Findings and Decision regarding payment for said services.

DECISION AND ORDER

Respondent is entitled to reimbursement in the amount of $102.40 plus applicable accrued interest under CPT Code 97546-WH for services rendered on August 7, 2007.

Inasmuch as Petitioner has tendered to Respondent payment in the amount of $102.40 plus applicable accrued interest under CPT Code 97546-WH for services rendered on August 7, 2007, Petitioner is in compliance with the Medical Fee Dispute Resolution Findings and Decision regarding payment for said services.

ORDER

Petitioner is liable for the benefits at issue in this hearing. Claimant remains entitled to medical benefits for the compensable injury in accordance with the Texas Workers’ Compensation Act and the Commissioner’s Rules.

The true corporate name of the insurance carrier is SUA INSURANCE COMPANY; and the name and address of its registered agent for service of process is:

CT COPORATION SYSTEM

350 NORTH ST PAUL STREET

DALLAS, TX 75201

Signed this 1st day of July 2008,

Sandra Weber Fullerton
Hearing Officer

End of Document
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