454-13-3772-m4
DECISION AND ORDER Castlepoint National Insurance (Castlepoint) requested a hearing before the State Office of Administrative Hearings (SOAH) to challenge a Medical Fee Dispute Resolution Findings and Decision ordering it to reimburse Discovery Health Services (Discovery) $15,852.97 for chronic pain management (CPM) services provided to an injured worker (Claimant). Administrative Law Judge (ALJ) Gary Elkins […]
454-13-3807-m4
DECISION AND ORDER Travelers Indemnity Company (Carrier) challenges the Medical Fee Dispute Findings and Decision of the Texas Department of Insurance, Division of Worker’s Compensation (Division), that ordered reimbursement of an additional $3,345.04 to Harlingen Medical Center (Provider) for medical services provided to an injured worker (Claimant). The Administrative Law Judge (ALJ) concludes that Carrier […]
454-13-0601-m4
DECISION AND ORDER Facility Insurance Corporation (Carrier) challenges the October 1, 2012 Medical Fee Dispute Resolution Findings and Decision (MFDR Decision) of the Texas Department of Insurance, Division of Workers’ Compensation (Division). The MFDR Decision ordered Carrier to pay $14,309.72 in reimbursement to Methodist Hospital (Provider). The Administrative Law Judge (ALJ) finds that Provider did […]
454-13-3947-m4
DECISION AND ORDER Facility Insurance Corporation (Carrier) challenges the order granting additional reimbursement to Patients Medical Center (Provider) for services provided to an injured worker. The Administrative Law Judge (ALJ) concludes that Provider is entitled to additional reimbursement from Carrier for the services provided. I.JURISDICTION, NOTICE, AND PROCEDURAL HISTORY There are no issues of notice […]
454-13-0111-m4
DECISION AND ORDER BASED UPON STIPULATIONS Pacific Employers Insurance Company (PEIC) challenges the award of additional reimbursement to Texas Orthopedic Hospital (TOH) for hospital outpatient services performed at TOH for an injured worker on August 8-9, 2008. The parties have stipulated the PEIC paid the amount due TOH under the applicable fee guideline. The Administrative […]
454-13-4648-m4
DECISION AND ORDER Texas Mutual Insurance Company (TMIC) challenges the Texas Department of Insurance, Division of Workers’ Compensation (DWC) Medical Fee Dispute Resolution Findings and Decision of April 26, 2013 (Decision) ordering TMIC to pay Metropolitan Methodist Hospital (MMH) $9,011.34 for inpatient hospital surgical services provided to an injured worker during the period January 3, […]
454-13-0881-m4
DECISION AND ORDER ____ challenges the denial of reimbursement by Dallas Area Rapid Transit (DART) for homecare she provided. DART denied reimbursement based on its conclusion, among other reasons, that ____ was, at the time of the disputed services, neither a licensed certified health care practitioner nor a non-licensed individual who provides or renders healthcare […]
454-13-2726-m4
DECISION AND ORDER Shannon Medical Center (Provider) seeks reimbursement for outpatient surgical services provided to a worker’s compensation claimant. Employers Insurance Company of Wausau (Carrier) denied reimbursement because the surgery was not preauthorized and was not provided pursuant to an emergency. Based on the lack of preauthorization, the Administrative Law Judge (ALJ) concludes that Provider […]
454-13-0853-m4
DECISION AND ORDER Liberty Insurance Corporation (Carrier) challenges the order of reimbursement to Baylor Orthopedic and Spine Hospital (Provider) for outpatient surgical services provided to an injured worker (Claimant). The Administrative Law Judge (ALJ) concludes that Carrier met its burden of proof that the amount of reimbursement ordered was incorrect. Nevertheless, Carrier owes Provider $80.68 […]
454-13-0855-m4
DECISION AND ORDER Public WC Program (Carrier) challenges calculations contained in a Medical Fee Dispute Resolution decision (MDR Decision) by the Texas Department of Insurance (TDI), Division of Workers’ Compensation (Division). The MDR Decision calculations show that Carrier should pay additional reimbursement to Northwest Texas Hospital (Provider) for outpatient facility services provided to an injured […]