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At a Glance:
Title:
09009
Date:
July 30, 2008
Status:
Medical Fees

09009

July 30, 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 July 24, 2008, to decide the following disputed issue:

  1. Whether the health care provider is entitled to $568.44 for services rendered to Claimant on February 28, 2007?

PARTIES PRESENT

Petitioner/Subclaimant appeared and was represented by Mr. G, lay representative. Carrier appeared and was represented by RJ, attorney.

BACKGROUND INFORMATION

The health care provider (HCP) rendered services to Claimant on February 28, 2007. On March 23, 2007, the HCP mailed a request for payment in the amount of $568.44 to a servicing contractor for Carrier. However, the bill was submitted under the wrong claim number. On May 1, 2007, Mr. G, the lay representative herein for the HCP, called an adjuster for Carrier and was told that the bill had been denied on April 17, 2007, because of an incorrect claim number. Mr. G's notes which were offered by the HCP and admitted into evidence reflect that Mr. G was aware that the HCP needed to correct the claim number. Mr. G made several calls to the adjuster prior to the time the HCP submitted a new bill to the Carrier on or after July 12, 2006. On July 16, 2007, Carrier finally received the former incomplete bill as a new bill.

Carrier asserts that it is relieved of liability for the bill of $568.44, because it did not receive a complete bill as required under Rule 133.20. Rule 133.20 (b) states, "A health care provider shall not submit a medical bill later than the 95th day after the date the services are provided." Rule 133.20 (g) states, "Health care providers may correct and submit as a new bill an incomplete bill that has been returned by the insurance carrier." The rule requires that a bill for medical services should be submitted timely, accurately and completely. If a new bill is required, it must the sent to the Carrier not later than the 95th day after the date of service which would herein require an accurate and complete bill not later than June 2, 2007. Because the health care provider did not timely and accurately submit a complete and correct medical bill, the health care provider is not entitled 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 ______________, Claimant was the employee of (Employer), when she sustained a compensable 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.
  • The health care provider did not timely and properly submit a medical bill for the reimbursement of $568.44 until after the expiration of the 95th day after the date the services were provided.
  • 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 health care provider is not entitled to reimbursement of $568.44 for services rendered on February 28, 2007.

    DECISION

    The health care provider is not entitled to reimbursement of $568.44 for services rendered on February 28, 2007.

    ORDER

    Carrier is not liable for the reimbursement 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 ACE AMERICAN INSURANCE COMPANY and the name and address of its registered agent for service of process is

    ROBIN M. MOUNTAIN

    6600 CAMPUS CIRCLE DRIVE EAST, SUITE 300

    IRVING, TEXAS 75063

    Signed this 30th day of July, 2008.

    Charles T. Cole
    Hearing Officer

    End of Document
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