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At a Glance:
Title:
09224
Date:
July 28, 2009
Status:
Medical Fees

09224

July 28, 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 medical prehearing conference was held on 4/14/08, and a contested case hearing was held on July 6, 2009 to decide the following disputed issue:

  1. Is the preponderance of the evidence contrary to the findings of Medical Fee Dispute Resolution that the health care provider is entitled to $130.00 for CPT code 97530, 97110, 97032, 97035 for services rendered to Claimant on January 22, 2007?

PARTIES PRESENT

Claimant did not appear and his appearance is waived in this matter.

Petitioner/Carrier appeared and was represented by BP, attorney

Respondent/provider did not appear for the hearing and did not respond to a 10-day letter from the Division.

BACKGROUND INFORMATION

Provider did not appear for the hearing scheduled on July 6, 2009 and did not respond to a ten day letter from the Division. On January 22, 2007, the health care provider provided service to the claimant for his compensable injury. The Carrier seeks reimbursement in the amount of $130.00 for the amount paid to the healthcare provider. The Carrier stated that payment for the date of service was denied because the bill was not timely submitted within 95 days. The Carrier failed to submit any evidence establishing that the bill was untimely filed and therefore did not meet its burden. Evidence in the form of a CMS 1500 demonstrated timely filing. The Petitioner filed a request for Medical Fee Dispute Resolution and on April 14, 2008 the Dispute Resolution Officer issued a finding that Dr. J was entitled to payment of $130.00 for the date of service on 1/22/07 for CPT codes 97530, 97110, 97032, and 97035. The Medical Fee Dispute Resolution officer found that the provider sent the bill to the Carrier on time. Division Rule 102.4(h) the bill was timely submitted. Rule 102.4 (h) states as follows:

“(h) Unless the great weight of evidence indicates otherwise, written communications shall be deemed to have been sent on:

(1) the date received, if sent by fax, personal delivery or electronic transmission or,

(2) the date postmarked if sent by mail via United States Postal Service regular mail, or, if the postmark date is unavailable, the later of the signature date on the written communication or the date it was received minus five days. If the date received minus five days is a Sunday or legal holiday, the date deemed sent shall be the next previous day which is not a Sunday or legal holiday.”

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 Carrier stipulated to the following facts:

A.The Texas Department of Insurance, Division of Workers’ Compensation has jurisdiction in this matter.

B.Venue is proper in the (City) Field Office of the Texas Department of Insurance, Division of Workers’ Compensation.

C. On ______________, Claimant was the employee of (Self-Insured), Employer.

D.Claimant sustained a compensable injury on ______________.

  • Carrier delivered to Petitioner a single document stating the true corporate name of Self-Insured Carrier, and the name and street address of Self-Insured Carrier’s registered agent, which document was admitted into evidence as Hearing Officer’s Exhibit Number 2.
  • The medical fee dispute resolution officer determined that the provider is entitled to reimbursement in the amount of $130.00 for the date of service of 1/22/07 for CPT codes 97530, 97110, 97032, and 97035.
  • The health care providers claim for $130.00 was timely submitted to the carrier for reimbursement in accordance with Texas Labor Code §408.027.
  • 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 preponderance of the evidence is not contrary to the findings of the Medical Fee Dispute Resolution that the health care provider is entitled to reimbursement in the amount of $130.00 for the date of service of 1/22/07 for CPT codes 97530, 97110, 97032 and 97035.

      DECISION

      Health care provider, Dr. J M.D., is entitled to reimbursement in the amount of $130.00 for the date of service of 1/22/07 for CPT codes 97530, 97110, 97032 and 97035.

      ORDER

      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 (SELF-INSURED) and the name and address of its registered agent for service of process is:

      EE, COUNTY JUDGE

      (STREET ADDRESS)

      (CITY), TEXAS (ZIP CODE)

      Signed this 28th day of July, 2009.

      Susan Meek

    4. Hearing Officer
    End of Document
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