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At a Glance:
Title:
09127
Date:
March 31, 2009
Status:
Medical Fees

09127

March 31, 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.

ISSUE

A benefit contested case hearing was held on March 23, 2009, to decide the following disputed issue:

Whether Self-insured is liable to (Health-Care Provider) in the amount of $741.05 for additional services rendered to the Claimant on October 26, 2007 for CPT codes 72141 and 72050?

PARTIES PRESENT

Self-insured appeared and was represented by attorney BP. Respondent appeared by telephone and was represented by Dr. DR. Claimant appeared and was assisted by LDA, ombudsman.

BACKGROUND

On December 24, 2007, Carrier received a bill from the Respondent/Subclaimant in the amount of $850.00 for CPT Code 70551 for services rendered on October 26, 2007. Carrier paid the bill.

It was not until July 22, 2008 that Carrier received a bill marked "REQUEST FOR RECONSIDERATION" for charges by Respondent/Subclaimant for additional services rendered on October 26, 2007, which charges totaled $930.00.

Although marked as a reconsideration request, the documents received by Carrier on July 22, 2008, had not been submitted to Carrier previously. On October 10, 2008, the Medical Fee Dispute Resolution Findings and Decision was issued ordering Carrier to pay the additional amount of $741.05 plus interest for the additional services billed for October 26, 2007.

The order also noted that “Per review of Box 32 on CMS-1500, zip code _____ is located in _____ County. The maximum reimbursement amount, under Rule 134.202(b), is determined by locality.” Based upon this information the reimbursement rate for CPT code 72141 ($540.17 x1.25%) was determined to be $675.00 and for CPT code 72050 ($52.67 x 1.25%) $65.84 totaling $741.05.

Section 408.027(a) of the Texas Workers' Compensation Act provides,

"A health care provider shall submit a claim for payment to the insurance carrier not later than the 95th day after the date on which the health care services are provided to the injured employee. Failure by the health care provider to timely submit a claim for payment constitutes a forfeiture of the provider's right to reimbursement for that claim for payment."

There is no provision under the Act or Rules allowing resubmission of an improperly submitted bill after the time period provided for in Section 408.027(a). Because the bill was not properly submitted before the expiration of the 95 day period, the health care provider forfeited the right to reimbursement for that claim for payment.

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

  • Self-insured delivered to Provider a single document stating the true corporate name of Self-insured, and the name and street address of Self-insured’s registered agent, which document was admitted into evidence as Hearing Officer’s Exhibit Number 2.
  • The health care provider did not submit a proper bill to carrier in the amount of $930.00 for additional services provided to Claimant on October 26, 2007, until after the 95th day after the date on which the health care services were provided to Claimant.
  • Medical Fee Dispute Resolution Findings and Decision was issued ordering Carrier to pay the amount of $741.05 plus interest for the additional services billed for October 26, 2007.

  • Carrier complied with the Medical Fee Dispute Resolution Findings and Decision by paying $741.05 with interest which was received by the Respondent on November 11, 2008.
  • 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. Self-insured is not liable to (Health-Care Provider) for the additional amount of $741.05 plus interest for the additional services billed for October 26, 2007.

    DECISION

    Self-insured is not liable to (Health-Care Provider) for the amount of $741.05 plus interest for the additional services billed for October 26, 2007.

    ORDER

    Self-insured is not 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 self-insured is (SELF-INSURED) and the name and address of its registered agent for service of process is

    AS

    SUPERINTENDENT

    (ADDRESS)

    (CITY), TEXAS (ZIP CODE)

    Signed this 31st day of March, 2009

    Katherine D’Aunno Buchanan
    Hearing Officer

    End of Document
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