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At a Glance:
Title:
453-01-2841-m4
Date:
January 24, 2002
Status:
Medical Fees

453-01-2841-m4

January 24, 2002

DECISION AND ORDER

This case is a dispute over whether additional reimbursement is appropriate. _______(Claimant) underwent certain medical procedures between September 5, 1999, and January 19, 2000, under the care of Clem C. Martin, D.C. (Provider). Provider billed American Home Assurance Company (Carrier) for these procedures. Carrier reimbursed Provider an amount it deemed appropriate. Carrier asserts Provider has been reimbursed in accordance with the Texas Workers’ Compensation Commission (Commission) Medical Fee Guideline. The amount in controversy is $411.00.

Neither Clem C. Martin, D.C., nor a representative of Dr. Martin appeared at the hearing after receiving proper notice. The only evidence was presented by Respondents. The ALJ finds Provider is not entitled to additional reimbursement by Carrier for medical procedures performed between 09/05/1999 and 1/19/2000.

I.

FINDINGS OF FACT

  1. Claimant,__________ , suffered a compensable injury on ________.
  2. Claimant was referred to the Provider, Clem C. Martin, D.C., for treatment.
  3. The only dates eligible for review in this dispute are 8/16/1999 through 1/19/2000.
  4. Provider billed Carrier $39.00 for CPT Code 99054 performed on 9/5/1999. Carrier denied payment citing Provider failed to submit proper documentation.
  5. Provider billed Carrier $25.00 for CPT Code 99050 performed on 9/7/1999. Carrier denied payment citing Provider failed to submit proper documentation.
  6. Provider billed Carrier $10.50 for CPT Code 99080 performed on 9/9/1999. Carrier denied payment citing this procedure was the same as another procedure administered to Claimant during the same session. Carrier tendered $2.00.
  7. Provider billed Carrier $40.00 for CPT Code 95851 performed on 10/11/1999. Carrier denied payment citing Provider failed to assign the correct CPT Code.
  8. Provider billed Carrier $50.00 for CPT Code 99080 performed on 11/8/1999. Carrier denied payment citing Provider failed to submit proper documentation in accordance with rule 133.106(e). Carrier tendered $15.00.
  9. Provider billed Carrier $15.00 for CPT Code 99080-64 performed on 11/12/1999. Carrier denied payment citing Provider failed to submit proper documentation.
  10. Provider billed Carrier $3.00 for CPT Code 99080 performed on 11/15/1999. Carrier denied payment citing Provider failed to submit proper documentation. Carrier tendered $2.00.
  11. Provider billed Carrier $71.00 for CPT Code 99214-MP performed on 12/3/1999. Carrier denied payment citing Provider failed to submit proper documentation.
  12. Provider billed Carrier $7.00 for CPT Code 99080 performed on 12/13/1999. Carrier denied payment citing Provider failed to submit proper documentation. Carrier tendered $1.50.
  13. Provider billed Carrier $50.00 for CPT Code 99455-RP performed on 12/15/1999. Carrier denied payment citing Provider failed to assign the proper CPT Code.
  14. Provider billed Carrier $71.00 for CPT Code 99214-MP performed on 01/05/2000. Carrier denied payment citing Provider failed to submit proper documentation.
  15. Provider billed Carrier $50.00 for CPT Code 99455-RP performed on 1/19/2000. Carrier denied payment citing Provider failed to assign the proper CPT Code.
  16. For the procedures outlined in Findings of Facts Nos. 3-14, Provider billed Carrier a total of $431.40.
  17. For the procedures outlined in Findings of Facts Nos.3-14, Carrier reimbursed Provider a total amount of $20.50.
  18. Provider filed a Request for Medical Dispute Resolution with the Medical Review Division of the Texas Workers’ Compensation Commission (Commission), seeking additional reimbursement for the procedures outlined in Findings of Facts Nos.3-14.
  19. On March 12, 2001, the Commission’s Medical Review Division found Provider was not entitled to additional reimbursement other than the $20.50 previously tendered to Provider for the services outlined in Findings of Facts Nos. 3-14.
  20. Provider filed a request for hearing before the State Office of Administrative Hearings (SOAH).
  21. Notice of the hearing was sent May 8, 2001.
  22. The notice contained a statement of the time, place, and nature of the hearing; a statement of the legal authority and jurisdiction under which the hearing was to be held; a reference to the particular sections of the statutes and rules involved; and a short, plain statement of the matters asserted.
  23. The hearing was held December 10, 2001, with ALJ Steven M. Rivas presiding and representatives of the Carrier and the Commission participating. The Provider did not make an appearance. The hearing was adjourned the same day.
  24. The Provider offered no evidence disputing the findings of the Medical Review Division.
  25. For the medical services rendered to Claimant outlined in Findings of Facts Nos. 3-14, Provider has been fully reimbursed in accordance with the Commission’s Medical Fee Guideline.
  26. Provider is not entitled to additional reimbursement for the medical services outlined in Findings of Facts Nos. 3-14.

II. CONCLUSIONS OF LAW

  1. The Commission has jurisdiction over this matter pursuant to Section 413.031 of the Texas Workers' Compensation Act (the Act), Tex. Lab. Code Ann. ch. 401 et seq.
  2. SOAH has jurisdiction over this proceeding, including the authority to issue a decision and order, pursuant to Tex. Lab. Code Ann. § 413.031(d) and Tex. Gov’t Code Ann. ch. 2003.
  3. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. § 2001.052.
  4. The Provider, as Petitioner, has the burden of proof in this matter under 28 Tex. Admin. Code § 148.21(h).
  5. Provider is not entitled to additional reimbursement from Carrier for medical procedures outlined in the above Findings of Facts Nos. 3-14.

ORDER

IT IS, THEREFORE, ORDERED that Provider, Clem C. Martin, D.C., is not entitled to additional reimbursement of $411.00 from the Carrier, American Home Assurance Company, for the medical procedure performed between September 5, 1999, to January 19, 2000.

Signed January 24, 2002.

Steven M. RivasAdministrative Law Judge

State office of administrative hearings

End of Document
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