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At a Glance:
Title:
09111
Date:
March 10, 2009
Status:
Medical Fees

09111

March 10, 2009

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 contested case hearing was held on March 9, 2009 to decide the following disputed issue:

  1. Is the Petitioner, (Healthcare Provider), entitled to reimbursement in the amount of $191.61 for health care services (CPT Codes 97032, 97140, 97530-59 x2 units and 97110 x 2 units) rendered on May 7, 2007?

PARTIES PRESENT

Claimant did not appear and his appearance is waived in this matter. Petitioner/Provider, Dr. JR, appeared on his own behalf. Respondent/Carrier appeared and was represented by GS, attorney.

BACKGROUND INFORMATION

On May 7, 2007, the Petitioner’s clinic provided therapy services to the claimant for his compensable injury. The Petitioner seeks reimbursement in the amount of $191.61 for these services. These services were denied by the Respondent because a copy of the pre-authorization letter was not submitted with the bill. The Petitioner filed a request for Medical Fee Dispute Resolution and on May 8, 2008 the Dispute Resolution Officer issued a finding that the petitioner was not entitled to reimbursement for the same reason provided by the respondent, the preauthorization letter was not attached.

In evidence at the Medical Contested Case Hearing was a copy of the physical therapy visit summary and a pre-authorization approval letter from the carrier dated April 18, 2007. The letter indicates that the physical therapy was found to be medically necessary and services were approved for twelve visits. The therapy was to occur three times per week for four weeks from April 13, 2007 through June 13, 2007. The requested service date of May 7, 2007 falls within the pre-authorization period.

Based upon the evidence presented in this hearing, the petitioner has shown entitlement to reimbursement for the requested services.

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. The Texas Department of Insurance, Division of Workers’ Compensation has jurisdiction to hear this case

  • Carrier delivered to Provider 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.
  • Petitioner’s claim for $191.61 was submitted with a pre-authorization letter identifying approval of the modalities as required in accordance with Rule 134.600.
  • 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, (Healthcare Provider), is entitled to reimbursement in the amount of $191.61 for health care services CPT Codes 97032, 97140, 97530-59 x 2 units and 97110 x 2 units rendered on May 7, 2007.

    DECISION

    Petitioner, (Healthcare Provider), is entitled to reimbursement in the amount of $191.61 for health care services CPT Codes 97032, 97140, 97530-59 x 2 units and 97110 x 2 units rendered on May 7, 2007.

    ORDER

    Respondent/Carrier is 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 ZURICH AMERICAN INSURANCE COMPANY and the name and address of its registered agent for service of process is:

    LEO F. MALO

    12222 MERIT DR. SUITE 700

    DALLAS, TX 75251

    Signed this 10TH day of March, 2009.

    Jacquelyn Coleman
    Hearing Officer

    End of Document
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