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 pre-hearing medical fee dispute was scheduled to be held on September 12,

2008. At the September 12, 2008, pre-hearing, both Petitioner/Subclaimant and

Respondent/Carrier entered into an agreement on the record with respect to

the fee dispute for dates of service June 18, 2007, and June 25, 2007.

PARTIES PRESENT

Petitioner/Subclaimant appeared by telephone and was represented by JW. Respondent/Carrier appeared by telephone and was represented by BJ, attorney.

AGREEMENT

The parties reached an agreement. The agreement only resolves the issues to be decided at this hearing. The agreement does not resolve all issues regarding the claim and is not a settlement.

In this decision, this Agreement section includes findings of fact and the Decision section constitutes the conclusions of law.

Hearing Officer Findings:

1. Venue is proper in the (City) Field Office of the Texas Department of Insurance,

Division of Workers’ Compensation.

sustained a compensable injury.

The Parties agreed to the following:

1. To withdraw the disputed issue of “Whether the preponderance of the evidence is

contrary to the decision of Medical Review that the UB-92 was not submitted

timely in accordance with Section 408.027(a) which provides that a health care

provider shall submit a claim for payment to the insurance carrier not later than the

95^th day after the date on which the health care services are provided to the injured

employee, and since there was not a timely filing the Petitioner has forfeited the

right to reimbursement;” and

Subclaimant/(Health Care Provider) the Maximum Allowable Reimbursement

(MAR) in the amount of $472.38 for dates of service of June 18, 2007, and June 25,

2007.

DECISION

Texas Mutual Insurance Company/Respondent/Carrier agrees to pay to Petitioner/Sub-claimant/(Health Care Provider)the Maximum Allowable Reimbursement (MAR) in the amount of $472.38 for dates of service of June 18, 2007, and June 25, 2007.

ORDER

Carrier/Respondent is ordered to pay benefits in accordance with this decision, the Texas

Workers’ Compensation Act and the Commissioner’s Rules.

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:

RUSSELL OLIVER, PRESIDENT

TEXAS MUTUAL INSURANCE COMPANY

6210 EAST HIGHWAY 290

AUSTIN, TEXAS 78723

Signed this 12^th day of September 2008

Cheryl Dean
Hearing Officer