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At a Glance:
Title:
09044-m4r
Date:
November 3, 2008

09044-m4r

November 3, 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 set on 10/01/08, with the record closing on 10/30/08 to decide the following disputed issue:

  1. Is the preponderance of the evidence contrary to the Decision of

Medical Review that the Petitioner / Provider, (Health Care Provider), is not entitled to reimbursement of $1568.00 for dates of service between

06/13--22/07 under CPT Codes 97545 and 97546?

PARTIES PRESENT

Petitioner appeared and was represented by JE, lay representative. Respondent appeared and was represented by JC, attorney. Claimant's appearance was waived.

BACKGROUND INFORMATION

(Health Care Provider), Petitioner, treated Claimant for the __________ compensable injury. This is a non-network claim. (Health Care Provider) requested reimbursement for services provided between 06/13--22/07. Carrier's vendor denied payment stating the bills were not timely filed. The case went to Medical Review which upheld the Carrier's denial stating there was no convincing evidence the bills were timely filed. The Parties stipulated Claimant had a compensable injury on __________, and (Health Care Provider) provided the medical services represented by the disputed bills. Carrier acknowledges receiving medical records timely, but insists no bills were received timely.

Texas Labor Code Section 408.027 states that a provider must submit a claim for payment not later that the 95th day after the health care services are provided to the injured worker. In this case, (Health Care Provider) submitted their claim to a clearinghouse for distribution to the Carrier. Mail receipts reflect (Health Care Provider)'s vendor timely sent records to the Carrier. The Carrier submits the bills to their clearinghouse for payment. The bills were not paid, and (Health Care Provider) filed for reconsideration.

AC, claims adjuster, testified she knew the Claimant was receiving extensive medical treatment for the compensable injury. She was not aware their vendor had not made payment until the request for reconsideration came in. She approved the request and sent the information back to their vendor for payment. She did not see the actual bills, and was surprised when payment was again denied.

Medical review upheld Carrier's denial of payment stating there was no convincing evidence that the bills were submitted timely. At this hearing, (Health Care Provider) presented convincing evidence that the bills were submitted timely. There is confirmation regarding mailing and delivery of the claim. Carrier acknowledged the treatment was provided, and some records (everything but the bills) were received timely. Carrier's argument that the bills were left out of the records is not persuasive.

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), Employer.

C. Claimant was injured in the course and scope of his employment on __________.

  • 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.
  • (Health Care Provider) provided medical services to the Claimant, for this compensable injury, between 06/13--22/07.
  • (Health Care Provider) timely submitted bills for this medical service to the Carrier.
  • Carrier received the bills within 95 days of the date the services were rendered.
  • The preponderance of the evidence is contrary to the decision of Medical Review that the
  • Petitioner / Provider, (Health Care Provider), is not entitled to reimbursement of $1568.00 for dates of

    service between 06/13--22/07 under CPT Codes 97545 and 97546.

    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. Petitioner / Provider, (Health Care Provider), is entitled to reimbursement of $1568.00

    for dates of service between 06/13--22/07 under CPT Codes 97545 and

    97546.

    DECISION

    The preponderance of the evidence is contrary to the Decision of Medical Review

    that the Petitioner / Provider, (Health Care Provider), is not entitled to reimbursement of

    $1568.00 for dates of service between 06/13--22/07 under CPT Codes 97545 and

    97546.

    Petitioner / Provider, (Health Care Provider), is entitled to reimbursement of $1568.00

    for dates of service between 06/13--22/07 under CPT Codes 97545 and 97546.

    ORDER

    Carrier is ordered to pay benefits in accordance with this Decision, the Texas Workers’ Compensation Act, and Commissioner’s Rules.

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

    CT CORPORATION SYSTEMS

    350 N. ST. PAUL STREET

    DALLAS, TEXAS 75201

    Signed this 3rd day of November, 2008.

    G. W. Quick

    Hearings Officer

    End of Document
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