In the Texas workers’ compensation system, reimbursement for most medical services and treatments not provided through a workers’ compensation health care network is determined by the Division of Workers’ Compensation (DWC) fee guidelines. These fee guideline rules are based on the Texas Workers’ Compensation Act and adopted through the administrative rulemaking process.
DWC medical reimbursement policy and fee guideline rules in 28 Texas Administrative Code (TAC), Chapter 134 - Benefits - Guidelines for Medical Services, Charges, and Payments provide the methodologies used to determine appropriate reimbursement amounts, explain reimbursement requirements when a service or treatment is not addressed in a guideline, and clarify when DWC fee guidelines apply to medical services and treatments provided through a workers’ compensation health care network.
Understanding DWC medical reimbursement policies and fee guideline rules is crucial to successful reimbursement for workers' compensation claims.
For more information, contact us at 800-252-7031, option 3 or CompConnection@tdi.texas.gov.
Medical reimbursement policies
Chapter 134 - Benefits - Guidelines for Medical Services, Charges, and Payments, Subchapter A. Medical Reimbursement Policies
Medical fee guidelines apply to professional medical services and workers’ compensation specific codes, services, and programs. These fee guidelines do not apply to health care facility services, prescription drugs, and dental services.
Rules:
Chapter 134 - Benefits - Guidelines for Medical Services, Charges, and Payments, Subchapter C. Medical Fee Guidelines
- 134.203 Medical Fee Guideline for Professional Services
- 134.209 to §134.250 Medical Fee Guideline for Workers' Compensation Specific Services
- 134.209 Applicability
- 134.210 Medical Fee Guideline for Workers' Compensation Specific Services
- 134.215 Home Health Services
- 134.220 Case Management Services
- 134.225 Functional Capacity Evaluations
- 134.230 Return to Work Rehabilitation Programs
- 134.235 Return to Work/Evaluation of Medical Care
- 134.239 Billing for Work Status Reports
- 134.240 Designated Doctor Examinations
- 134.250 Maximum Medical Improvement Evaluations and Impairment Rating Examinations
Medical Fee Guidelines Resources:
The hospital fee guidelines are applicable to services provided in acute care hospitals appropriately licensed by the Texas Department of State Health Services.
Rules:
Chapter 134 - Benefits - Guidelines for Medical Services, Charges, and Payments. Subchapter E. Health Facility Fees
The Ambulatory Surgical Center (ASC) Fee Guideline applies to services provided in ambulatory surgical centers licensed by the Texas Department of State Health Services.
Rule and resources:
Chapter 134 - Benefits - Guidelines for Medical Services, Charges, and Payments. Subchapter E. Health Facility Fees
- 134.402 Ambulatory Surgical Center Fee Guideline
- ASC FAQ
- Calculations examples for Ambulatory Surgical Center Fee Guidelines
The pharmacy fee guideline applies to reimbursement of prescription drugs and nonprescription drugs or over-the-counter medications for outpatient use in the Texas workers’ compensation system.
Rule and resources:
Chapter 134 Benefits – Guidelines for Medical Services, Charges, and Payments. Subchapter F. Pharmaceutical Benefits
- 134.503 Pharmacy Fee Guideline
- Pharmacy homepage - includes information concerning the closed formulary and all other pharmacy rules.
- Pharmacy billing form - Statement of Pharmacy Services (DWC Form-066)
This section applies to professional dental services provided in the Texas workers’ compensation system.
Rules and resources:
Chapter 134 Benefits - Guidelines for Medical Services, Charges, and Payments. Subchapter C. Medical Fee Guidelines
- 134.303 - 2005 Dental Fee Guideline
- Instructions for Completing the ADA J515 Dental Claim Form for Texas Workers' Compensation Claims (DWC Form-070)
A federal military treatment facility (FMTF) is a medical facility that operates as part of the Military Health System of the United States Department of Defense. FMTFs are not subject to the Texas workers’ compensation statutes and rules for medical bill processing and payment, including DWC fee guidelines. Consequently, specific requirements for Texas workers’ compensation insurance carriers processing and payment of medical bills from FMTFs and a separate medical dispute resolution process to resolve disputes over charges billed directly to an injured employee by an FMTF are established by DWC rules.
Rules:
Chapter 134 - Benefits - Guidelines for Medical Services, Charges, and Payments, Subchapter B. Miscellaneous Reimbursement
Health care provider training and resources webpage
On demand videos (YouTube playlist)
- Health Care Provider Billing Procedures
- Reimbursement for Professional and Workers’ Compensation Specific Services
- Texas Workers’ Compensation Reimbursement Policies and Methodologies
- Medical Fee Dispute Resolution (MFDR)
- Billing and Reimbursement for Designated Doctor Examinations and Required Medical Examinations
- Billing and Reimbursement for Maximum Medical Improvement and Impairment Rating Examinations by Certifying Doctor
Live webinars (webinar schedule)
Other resources