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At a Glance:
Title:
11154
Date:
June 24, 2011
Status:
Medical Fees

11154

June 24, 2011

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 June 6, 2011 to decide the following disputed issues:

Is (Healthcare Provider) entitled to $432.00 for services rendered on January 11, 2010, January 12, 2010 and January 13, 2010 for the compensable injury of (Date of Injury)?

Did (Healthcare Provider) submit the medical bill and documentation for the services in dispute timely?

PARTIES PRESENT

Petitioner/Carrier was represented by SC, attorney. Respondent/(Healthcare Provider) appeared by and through CM, layperson. Claimant did not appear and his attendance was waived.

BACKGROUND INFORMATION

(Healthcare Provider) provided services on January 11, 2010, January 12, 2010 and January 13, 2010. (Healthcare Provider) filed its initial bill on February 25, 2010 and a corrected bill on July 28, 2010. On February 7, 2011 the Division, through a Medical Fee Dispute Resolution Findings and Decision, ordered Carrier to pay (Healthcare Provider) $432.00.

At this hearing, Carrier argued that although (Healthcare Provider) submitted its initial bill within 95 days after the date of service, it was incorrectly coded with an invalid diagnosis code and therefore the bill was incomplete. Carrier also contended that when (Healthcare Provider) submitted a corrected bill with the valid diagnosis code, it was not within the 95 days from the date of service timeframe.

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 rights for reimbursement for the claim for payment.”

The bill must be complete with any corrections submitted during the 95 day period. See MCCH No. 08058.

There is no provision under the Act or Rules allowing resubmission of an improperly submitted bill after the 95 day period provided for in Section 408.027(a). See MCCH NO. 09101. Services were provided on January 11, 2010, January 12, 2010 and January 13, 2010. Ninety five days from dates of service were April 15, 2010, April 16, 2010, and April 17, 2010, respectively.. (Healthcare Provider) did not submit its corrected bill until July 28, 2010. Because the bill was not properly submitted before the expiration of the 95 day period, (Healthcare Provider) forfeited the right to reimbursement for that claim for payment.

Even if 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 present 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 (Date of Injury), Claimant was the employee of (Employer).

C. Medical Fee Dispute Resolution Findings & Decision determined that Respondent is entitled to reimbursement for the services involved in this dispute in the amount of $432.00.

  • Carrier delivered to (Healthcare 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.
  • Claimant sustained a compensable injury of (Date of Injury).
  • The services provided by (Healthcare Provider) on January 11, 2010, January 12, 2010 and January 13, 2010 were health care reasonably required for Claimant’s compensable injury.
  • (Healthcare Provider) did not submit a properly coded bill to Carrier for services provided Claimant on January 11, 2010, January 12, 2010 and January 13, 2010, until after the 95th day after the dates on which the health care services were provided to Claimant.
  • Because (Healthcare Provider)’ bill was not timely submitted, (Healthcare Provider) is not entitled to reimbursement for the services involved in this dispute in the amount of $432.00.
  • 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. (Healthcare Provider) is not entitled to reimbursement of $432.00 for services rendered on January 11, 2010, January 12, 2010 and January 13, 2010 for the compensable injury of (Date of Injury).
    4. (Healthcare Provider) did not timely submit the medical bill and documentation for the services in dispute.

    DECISION

    (Healthcare Provider) is not entitled to reimbursement of $432.00 for services rendered on January 11, 2010, January 12, 2010 and January 13, 2010 for the compensable injury of (Date of Injury). (Healthcare Provider) did not submit the medical bill and documentation for services in dispute timely.

    ORDER

    Carrier 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 insurance carrier is TRAVELERS INDEMNITY COMPANY and the name and address of its registered agent for service of process is

    CORPORATION SERVICE COMPANY

    d/b/a CSC-LAWYERS INCORPORATING SERVICE COMPANY

    211 EAST 7TH STREET STE 620

    AUSTIN, TX 78701-3218

    Signed this 24th day of June, 2011.

    Judy L. Ney
    Hearing Officer

    End of Document
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