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Health Care Insurer Reimbursement under Labor Code

§ 140.7

Health Care Insurer Reimbursement under Labor Code

(a) Applicability. This section applies only to subclaims by a health care insurer based on information received under Labor Code § 402.084(c-3).

(b) Health care insurer. “Health care insurer” means an insurance carrier and an authorized representative of an insurance carrier, as described by Labor Code § 402.084(c-1).

(c) Reimbursement of Health Care Insurers. A health care insurer may be reimbursed for medical benefits provided to or paid on behalf of an injured employee with a compensable workers' compensation claim in accordance with Labor Code § 409.0091, the procedures of § 140.8 of this title (relating to Procedures for Health Care Insurers to Pursue Reimbursement of Medical Benefits under Labor Code § 409.0091), and this section.

(d) Certain Defenses Not Allowed. A workers' compensation insurance carrier shall not deny a reimbursement request under Labor Code § 409.0091 from a health care insurer because:

(1) the health care insurer has not sought reimbursement from the health care provider or the health care insurer's insured;

(2) the health care insurer or the health care provider did not request preauthorization under § 134.600 of this title (relating to Preauthorization, Concurrent Review, and Voluntary Certification of Health Care) or Labor Code § 413.014; or

(3) the health care provider did not bill the workers' compensation insurance carrier, as provided by Labor Code § 408.027, before the 95th day after the date the health care for which the health care insurer paid was provided.

The provisions of this § 140.7 adopted to be effective September 23, 2008, 33 TexReg 8002.

End of Document